care plan presentation, please guide

follow the steps of the nursing process in sequence:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

step #1 (assessment) - much of the physical assessment has been given to you. i sort of jumped the gun and listed the abnormal data which becomes the symptom list in step #2:

• very diaphoretic
  
• mildly lethargic
  
• complaining of abdominal pain and nausea
  
• hyperventilates
  
• acetone breath
  
• blood glucose of 450mg/dl
  
• ph: 6.9 (acidosis)
  
• pco2: 20mmhg (low - metabolic acidosis)
  
• hco3: 12meq/l (low - metabolic acidosis)
  
• na: 128 meq/l (low)
  
• k+: 3.0meq/l (low)
  
• pulse 88, rapid but regular

you can't do an adl assessment on this patient because it is a case study and this is an intensive care patient who is pretty much confined to bed at the moment. however, he does have the following medical conditions:

• dka (diabetic ketoacidosis)
  
• history of diabetes type i
  
• anxiety
  
• depression

and you really should be looking up the signs and symptoms as well as the tests and treatments that are ordered for these conditions as well as something about their pathophysiology. you are going to find that many of the items on the assessment list are signs and symptoms of dka.

i'm not sure what your instructor is looking for with assessment criteria. maybe all the assessment data, or just the abnormal data. you probably need to clarify that with the instructor. however, i would tend to think that you need to provide nursing assessment criteria, not medical assessment criteria. remember, we are nurses, not doctors.

nursing diagnoses are always based upon the abnormal assessment data (symptoms, or nanda defining characteristics) that the patient has.

a nursing diagnosis is not the same as a medical diagnosis. doctors do their thing with diagnosing and we do our thing. forget about dka. it's nice to know that information, but it's not that relevant to a nursing diagnosis. that's why i tell you to make a list of the patient's symptoms in the first part of step #2 of the nursing process. you need that list. everything else from then on that you do for the care plan is dependent on what is on that list.

you know that mosby's handbook of nursing diagnosis, 7th edition, that you have? well, right under each nursing diagnosis is the nanda information (from the taxonomy) about each diagnosis: definition, defining characteristics (symptoms) and related factors (etiology or causes--often the underlying pathophysiology causing the problem). the definition is the "real" problem and you should take the time to read these. the 3 and 4 word "nursing diagnoses", as we commonly call them, are actually shortened labels that represent these definitions. you also must realize that your patient must have one or more of the defining characteristics listed for that diagnosis or you really shouldn't be using it.

the hyperventilation is contributing to the acidosis and probably anxiety as well. the nursing diagnosis to use for this is ineffective breathing pattern r/t acid-base imbalance and anxiety aeb hyperventilation.

the high blood sugar combined with the vigorous exercise probably put the patient in his dka. he has imbalanced nutrition: less than body requirements r/t failure to ingest enough food aeb blood glucose of 450mg/dl.

this patient is in metabolic acidosis and has a lot of the symptoms (medical disease symptoms) of it. he is complaining of nausea and excessive diaphoresis. his ph and co2 are low. there's no mention of other loss of fluids, but i'm thinking that it has to be there. without the symptoms of deficient fluid volume, however, i think the best you can go for is risk for deficient fluid volume r/t hypermetabolic state

i wouldn't address anything else as those symptoms will go away as the blood sugar and electrolyte are brought under control. you can't care plan everything little thing going on.

the next thing you have to do is develop goals and nursing interventions for the hyperventilation, the elevated blood sugar and the potential fluid loss (i'm thinking through possible polyuria, diaphoresis and vomiting) in the three nursing diagnoses.

and that should give you some direction to go with this. remember, we are nurses, not doctors. you have to keep the medical information separated from the nursing information in your mind.

daytonite, thank you very much for responding to my mail. i will start rewriting and if i have any questions/ clarifications, can i please ask you?!

of course. some times it takes me time to respond. depends on the time of day, whether i can get connected to the internet easily and if i am feeling well enough. since my chemotherapy i have no feeling in my fingers and have a great deal of difficulty typing.

Glad to hear you are meeting with your instructor. You know, care planning can be a little confusing and slow going at first. But, hang in there and don't give up. After doing a few of these and starting to "get" what this nursing process business is all about, a light bulb goes on and you're suddenly in a horse race you feel confident you can't lose! It took me a while to finally "get" it, but when I did it was like Christmas came early. Now, every time a patient problem comes up I automatically start thinking, "What information do I know?", "What else do I need to find out?", "What needs to be done first, second, third, etc,?" It also helps after you've taken care of more than one or two patients with the same problem. It lets you correct prior errors in judgment that you previously made (and, believe me, you'll make plenty of those! That, unfortunately, is how we all learn to improve.)

not a problem. if i didn't make the importance of step #1 assessment clear in this post, i did in my posts to these threads:

• https://allnurses.com/forums/f205/help-nursing-care-plans-277791.html
  
• https://allnurses.com/forums/f8/desparately-need-help-care-plan-279187.html
  
• https://allnurses.com/forums/f205/need-help-w-1st-care-plan-please-help-286723.html
  
• https://allnurses.com/forums/f205/care-plan-help-280901.html

make sure you coordinate your assessment data with the person doing the nursing diagnoses. also, it's important that you understand that the medical disease information is important to know, particularly the pathophysiology. the pathophysiology gives you the important etiology link for the nursing diagnostic statements.

just for your protection, there are weblinks to how to get along with others when doing group assignments. might be a good idea to read these guidelines just in case your instructors are among those that turn students loose on group projects without giving them any rules or guidelines in case you end up with a few dud students who end up not pulling their share of the assignment so you know what to do.

• https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms - see post #39 for the group project weblinks

still needs work. look up what happens with untreated diabetes (the pathophysiology). the person literally starves as the body starts utilizing stores of fat even though their blood sugar is rising. the metabolism of the fats by the body for energy is what produces the ketosis. fruity breath is a symptom of this build up of acetone, a byproduct of fat metabolism, in the blood.

remember i said in the nursing process that part of your assessment activity that you need to learn about the pathophysiology of the disease. each step of the pathophysiology produces a manifestation we can see as a sign or symptom from the barely noticeable to death in the most severe diseases. you need to know that chain of events. if it will help you, use the critical thinking flow sheet for nursing students. the link is attached to the end of each of my posts. just click on it to open it up. you can download and print it out.

Aw, shucks! My face is redder than my finger tips (side effect of the chemotherapy)!