Care Plan

nursej22, MSN, RN · Feb 22, 2018

OP this is not directed at you, but climbing onto my soapbox,

Oh for Pete's Sake! What has happened to using one's assessment of the patient to formulate the care plan?

Or is this the trend of nursing school now, assign a medical diagnosis and let a student make something up?

A patient could have all the above diagnoses, but have something else in his assessment that points to a particular nursing dx that is not even related.

Anyhoo, 15 outcomes for each? That seems excessive. But if you list what you have, we may be able to help.

RNUM2121 · Feb 22, 2018

Oh I agree!! There is obviously more going on with the patient but this is what I had the most evidence for to create 15 outcomes and interventions.

For fluid volume excess so far I have...

1.Patient's volume is normal as evidenced by UO of 30 ml/hr.

2.I&O within normal limits 2000ml

3.Patient's sodium levels are within normal range 135-145.

4.BP is within normal range 120/80.

5.Patients HR is between 60-90

6.Patient implements turn schedule & increases activity q2 hrs.

7.Patient perform's normal ROM.

8.Patient performs ADLs as necessary.

9.Patient has significantly decreased evidence of edema in lower extremities.

10.Patient maintains normal electrolyte balance.

11.Patient verbalizes increase in knowledge in prevention and maintenance of fluid volume excess.

12.Fluid volume in normal range as evidenced by weight gain of 5lbs.

13.Remains free of jugular vein distension.

14.Maintains normal peripheral pulses and cardiac output.

If any of these are wrong or could be better just let me know! Im still learning

RNUM2121 · Feb 22, 2018

As far as an assessment goes...The patient is A&O x3, normocephallic with no JVD. He has an irregular heart beat and tachycardia (120's) despite the use of Beta blockers and Ca Channel blockers. The patient's BP is also elevated. His O2 status remain around 94% and he is on 5L/min humidified air NC. He has diminished breath sounds in the lower lobes bilaterally. The patients bowel sounds are normal but he does have tenderness and distention. His UO is normal for the 60mg of furosemide he is on however, urine is amber and has some sediment. The patient is voiding through a Foley Catheter, which I do not believe is the best option for this patient (but I am a student). He also is insistent on remaining prone in bed most of the day. His skin integrity is poor with hemosiderin throughout. He also has several necrotic toes r/t DM type II.

nursej22, MSN, RN · Feb 23, 2018

Oh I agree!! There is obviously more going on with the patient but this is what I had the most evidence for to create 15 outcomes and interventions.
For fluid volume excess so far I have...
1.Patient's volume is normal as evidenced by UO of 30 ml/hr.
2.I&O within normal limits 2000ml
3.Patient's sodium levels are within normal range 135-145.
4.BP is within normal range 120/80.
5.Patients HR is between 60-90
6.Patient implements turn schedule & increases activity q2 hrs.
7.Patient perform's normal ROM.
8.Patient performs ADLs as necessary.
9.Patient has significantly decreased evidence of edema in lower extremities.
10.Patient maintains normal electrolyte balance.
11.Patient verbalizes increase in knowledge in prevention and maintenance of fluid volume excess.
12.Fluid volume in normal range as evidenced by weight gain of 5lbs.
13.Remains free of jugular vein distension.
14.Maintains normal peripheral pulses and cardiac output.
If any of these are wrong or could be better just let me know! Im still learning

I am not sure if you need to include the word "normal" in your outcomes; if I was your instructor I would assume that you know what normal is. I do like that you include actual values however.

I am not sure I understand what you mean by I&O WNL 2000. Does this mean 2000 in and out? Is there a better way to phrase this? Like Output should remain = or > intake?

Sodium is an electrolyte, so i don't think these qualify as 2 different outcomes. But there is at least 1 other electrolyte you ought to monitor...

Do you really want them to maintain fluid volume excess?

Again, I don't understand what #12 means.

#9 what does decreased evidence of edema looks like?

How will you know that they have normal peripheral pulses (describe them)

And how do you assess cardiac output?

OneWhisper · Feb 24, 2018

Based on your assessment, it seems that there are more important diagnoses you could be using. But these are important as well.

As for the ineffective tissue perfusion diagnosis, here's some thoughts:

Nursing management for ineffective tissue perfusion would be aimed at removing vasoconstricting factors, improving peripheral blood flow, reducing metabolic demands on the body, pt participating and understanding the disease process and its treatment, and preventing complications. How do you think this can be accomplished?

Pt identifies factors that improve circulation (what factors will those be?)
Pt exhibits growing tolerance to activity (how will pt show this? what will you look for to see pt has growing tolerance?)
Pt shows no further worsening/repetition of deficits (how will pt show this?)
Pt engages in behaviors or actions to improve tissue perfusion (what behaviors/actions are up to you to describe)
Pt maintains maximum tissue perfusion to vital organs AEB (you include your thoughts here)
Pt verbalizes or demonstrates normal sensations and movement as appropriate (your thoughts as to what normal sensations and movement are appropriate for the pt)
Pt identifies changes in lifestyle that are needed to increase tissue perfusion, including (you include your thoughts here)
Pt states when to contact physician or health care professional (what will you teach pt to look for to know when the pt will contact physician)

You include the specifics and how each will be measured (i.e., how exactly the pt will show each of these - Like how will the pt maintain maximum tissue perfusion to vital organs, what will you look for to know this was achieved - also include the time-frame. In other words, make them into SMART goals.