care plan presentation, please guide

Daytonite, BSN, RN · Mar 17, 2008

follow the steps of the nursing process in sequence:

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)
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)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
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.

gaajr1, RN · Mar 17, 2008

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?

Thanks again!

Daytonite, BSN, RN · Mar 18, 2008

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.

gaajr1, RN · Mar 18, 2008

Daytonite,

How can I ever thank you. Inspite of all that's going on you make an effort to answer our questions, and that is simply amazing. I pray for you from the bottom of my heart and I know you will be fine. The world needs more people like you.

Please don't worry, ONLY reply if you can. But first,take care of yourself.

PS: I took an appointment with my instructor to clarify what you asked me to. I have it tomorrow. I will get back to you after writing a better care plan(hopefully).

Daytonite, BSN, RN · Mar 18, 2008

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.)

gaajr1, RN · Mar 19, 2008

Daytonite,

I met my instructor today and there are a couple of surprises. One, she made our presentations into a group project, but will be graded individually(on the material we write and on our presentation as such).

Second, in view of that I have to work only on assessment criteria.

Third, she wants nursing assessment and medical assessment to be included; she wants explanation as to why we need to do each of them and include all the base line screening before beginning therapy and any potential adverse effects etc.

I will start working on this and and if you are able to, then it would be great if you can review it. Hope I am not asking too much? Thanks!

Daytonite, BSN, RN · Mar 20, 2008

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:

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

gaajr1, RN · Mar 20, 2008

Daytonite,

My God, it just seemed like you know what's going with me right now! Yes, there are 3 other students working on this project and one of them in particular who is doing the diagnosis has no clue like me. I gave her all the guidelines that you always told me and everything else but she doesn't seem interested. The other 2 are alright but dislike constructive criticism. Added to all this, our instructor is the type you just mentioned.

Right now everything does seem like an uphill task but I want to take this as a challenge and do it. I will surely look into the site and see what best I can do for the group.

Thanks as always for the support and valuable tips. Take care.

gaajr1, RN · Mar 21, 2008

hello,

i wrote this for the assessment part of my presentaion. can you please tell me if this is alright. one question i have is, should the general symptoms of type 1/dka be mentioned? i ask this because, everything is not mentioned in the case study. i may sound foolish asking all these questions all the time but please bear with me:)

as per the case study, mr. j is showing the following signs and symptoms:

hyperventilation: when we breathe, we take in oxygen and exhale carbon dioxide. excessive breathing may lead to low levels of carbon dioxide in the blood. this may cause many of the symptoms that one feels when hyperventilating. with dka, the breathing tends to become deep and rapid as the body attempts to correct the blood acidity by getting rid of the ketones in the body. this is one of body's compensatory mechanisms.

acetone breath: a fruity odor to the breath occurs as the body attempts to get rid of excess acetone through breathing. this is one of the characteristic signs of ketoacidosis, which may occur in diabetes and is potentially a life threatening condition.

abg values: arterial blood gas sample provides a determination of the blood acid concentration (ph) in the body.

blood glucose: 450 mg/dl

ph: 6.9

pco2: 20 mm hg

hco3: 12 meq/l

na: 128 meq/l

k+: 3.0 meq/l

looking at the values of ph, pco2, and hco3 it shows metabolic acidosis. this can occur as a result of abnormal metabolism and patients with dka have a ph less than 7.3 (ph reflects h+ concentration; acidity increases as h+ concentration increases) and serum bicarbonates less than 15 meq/l. blood glucose levels greater than 250 mg/dl is a diagnostic feature for dka.

diaphoresis (profuse sweating), abdominal pain, lethargy are some of the symptoms that a dka patient can show.

please let me know, i want a feed back and i want to learn. thanks!

Daytonite, BSN, RN · Mar 21, 2008

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.

rn/writer, RN · Mar 21, 2008

Just wanted to thank you both, scrubaway010 and Daytonite, for putting together a thread that represents the give and take that we hope for in the student threads. The student puts forth effort and explains her thinking. The teacher/mentor gives her the tools to make it to the next step. The student uses those tools to go a bit further. The teacher/mentor is there waiting to guide her through the next part of the journey. The work is evident, and the thought process shows.

This is an absolute pleasure to witness. Such a nice contrast to the posts where folks come here asking others to do the work for them, even to the point of requesting that we pick a topic for their paper or research project. (Asking for help to choose among several named topics is okay, but not picking a topic off the top of our heads.)

I admire those who roll up their sleeves and dig in, asking for clarification or other help only when they have taken matters as far as they can on their own. It is students like this (like you scrubaway010) who will be able to internalize the knowledge and make it their own because they have participated fully in their own education.

Thank you for setting such a wonderful example.

And thank you, Daytonite, for giving so much of yourself. You are always in my prayers.