Careplan interpretation right?

PsychNurseWannaBe, BSN, RN · Oct 25, 2011

How many nursing diagnoses do you need?? It is kinda hard to say if you are on the right path because there is no assessment. I will provide more info in a bit, I have to look at your post again. Again, it is rather muddy because of the numerous nursing diagnoses. Some are not written correctly, some appear redundant.

cvenable · Oct 25, 2011

Well, we need one for each system: Resp, cardio, hydration/nutrition, etc. The client has chronic bronchitis, pneumonia, atrial pacemaker (from a MI), has had strokes, and is neutropenic. I know, coming up with a nursing diagnosis for each area is difficult. I find myself staring at the careplan wondering what I should focus on. For this one, he's extremely anxious, has terrible congestion, you can literally here him breathe while standing in the hallway with loud wheezes (my instructor wants to listen to lungs with us so she is sure we identify the sounds correctly). He has blood infusions daily.

PsychNurseWannaBe, BSN, RN · Oct 25, 2011

1) ineffective airway clearance r/t excessive mucus aeb wheezes throughout lung fields.

ineffective airway clearance is used when the patient is not able to clear his secretions. for example, ineffective coughing or the inability to remove secretions

2)risk for decreased cardiac output: risk factor malfunction of pacemaker.

doesn't make sense to me. this would not be care planned in regards to a possibility of a malfunctioning pacemaker. either it is malfunctioning or it isn't. if it is malfunctioning, i would assume it would be fixed asap.

plus you begin with a risk, you don't put a risk in again in the second half.

3)excess fluid volume r/t compromised regulatory mechanism secondary to myocardial infarction aeb taut, shiny skin, generalized edema. i'm not sure this a realistic goal. can nursing realistically address this? i thought meds may help, but i keep second guessing myself.

you do not keep having to put a secondary to in your nursing diagnosis (sometimes we do to clarify or draw attention to the why behind it, but don't think that you always have to). you can simply state; excess fluid volume r/t compromised regulatory mechanism aeb taut shiny skin, generalized edema. compromised regulatory mechanism is used when the system can not regulate sodium and water in the case of chf, liver or kidneys, iv fluids, diet, etc. .

4) chronic pain : chest pain r/t recurrent chronic coughing to expel airway secretions aeb reporting chest tightness and pain and shortness of breath.

pain, chronic r/t musculoskeletal chest wall pain secondary to chronic coughing aeb patient reports of pain while coughing to clear secretions???, how long has this been going on. if less than 3 months, than its pain, acute

5) activity intolerance r/t compromised oxygen transport system secondary to myocardial infarction, chronic bronchitis aeb shortness of breath, dyspnea, and increased respirations during activities.

activity intolerance r/t imbalance between oxygen supply and demand secondary to mi and chronic bronchitis aeb dyspnea and increased respiration during activities

6) risk for infection r/t compromised host defenses secondary to respiratory infection. i should be specific on the respiratory infection shouldn't i?

this can not be a risk for since he/she has an actual respiratory infection

7) risk for acute confusion r/t sleep deprivation

risk for acute confusion r/t disruption in sleep/wake cycle. consider disturbed sleep pattern

8) risk for constipation r/t diuretic use.

you have way too many nursing diagnoses. trim the list. you care plan is going to be pages and pages

9) risk for self-care deficient r/t activity intolerance.

no, you can not have this first part related to the second part as the second part is a nursing diagnosis and you already addressed this above. you can add interventions to the activity intolerance that would also cover the self-care deficit

10) anxiety r/t shortness of breath aeb inability to sleep. i'm not sure if this makes sense to anyone else but me.

did the patient report anxiety??

11) risk for sexual dysfunction r/t activity intolerance. can i use activity intolerance since it is a nursing diagnosis?

no

12) impaired social interaction r/t limited physical mobility aeb fatigue. again, not sure this one is proper.

is the patient having problems with social interactions?, if not, then it would not be care planned.

head spinning yet??? mine sure is. i thought i was pretty good at writing these until i i was graded on my last careplan. i think i tend to get too creative at times and miss the boat.

thank you in advance for your time!

ok:

again, i can not really and truly help you because i do not have an assessment. you do not need 12 nursing diagnoses unless you instructor told you to... if they did. they're cucko cucko. lol. trim this down. my answers may not be the most correct as some of your things were,..... well.... overwhelming.

you need to review nanda's definitions in regards to what nursing diagnosis is appropriate.

Vershonda · Oct 25, 2011

CVEnable,

The key to nursing diagnosis is to keep it simple i.e. risk for skin impairment related to limited physical activity. Risk for constipation related to impaoir mobility. The related to aspect of nursing diagnosis is what you assessed that could cause the problems.

PsychNurseWannaBe, BSN, RN · Oct 25, 2011

Well, we need one for each system: Resp, cardio, hydration/nutrition, etc. The client has chronic bronchitis, pneumonia, atrial pacemaker (from a MI), has had strokes, and is neutropenic. I know, coming up with a nursing diagnosis for each area is difficult. I find myself staring at the careplan wondering what I should focus on. For this one, he's extremely anxious, has terrible congestion, you can literally here him breathe while standing in the hallway with loud wheezes (my instructor wants to listen to lungs with us so she is sure we identify the sounds correctly). He has blood infusions daily.

Ugh... now I see this after I went through your care plan. I don't have anymore time tonight. Just remember to use the definitions according to NANDA as this is what most colleges want. I really feel for you if you have to do a care plan on each system. That is ridiculous. Who is to say that your patient has a problem in each of the body systems?

cvenable · Oct 25, 2011

LOL my instructor requires all 12. I knnow, my homework weekly for this one class is around 30 pages, typed, single spaced. We have 3 days to hand it in. So I hope you can understand my mind doing cart wheels. Yes, the client did report anxiety and unable to sleep and did state "he can not go anywhere anylonger because he gets winded leaving his living room", he has COPD (I think you gathered that) and gets transfusion because of anemia. By the way, I appreciate your assistance though overwhelming. I think my instructor really studied this client's chart because he was the most critical on the floor today. I always pick complicated clients because of how many nursing diagnoses we have to come up with and the one time I picked someone "easy", my careplan was a major disaster.

cvenable · Oct 25, 2011

Thank you both for your comments. psychnurse.. again, I appreciate your time. I will make MANY changes now and you gave me ideas actually on different things to focus on. I don't expect someone else to do my homework though I wish tonight I could pay someone to do it for me (my mind is mush).

PsychNurseWannaBe, BSN, RN · Oct 25, 2011

Thank you both for your comments. psychnurse.. again, I appreciate your time. I will make MANY changes now and you gave me ideas actually on different things to focus on. I don't expect someone else to do my homework though I wish tonight I could pay someone to do it for me (my mind is mush).

You are welcome.... :) You had a good start... a very good one. We appreciate it when students at least put forth an effort and you surely did!! It can just be hard for someone to step in and try to help when we don't get to see the patient. Especially with 12 NURSING DIAGNOSES. LOL :lol2:

xtxrn, ASN, RN · Oct 25, 2011

i'm working on a careplan and i researched many sites to figure out if what i have is okay, but again i just hope that my interpretation is correct. i'm going to post what i have and would love input and what i may be writing is wrong. i'm going to highlight where i think i may be incorrect.
how do these sound?
1) ineffective airway clearance r/t excessive mucus aeb wheezes throughout lung fields.
2)risk for decreased cardiac output: risk factor malfunction of pacemaker.
3)excess fluid volume r/t compromised regulatory mechanism secondary to myocardial infarction aeb taut, shiny skin, generalized edema. i'm not sure this a realistic goal. can nursing realistically address this? i thought meds may help, but i keep second guessing myself.
4) chronic pain : chest pain r/t recurrent chronic coughing to expel airway secretions aeb reporting chest tightness and pain and shortness of breath.
5) activity intolerance r/t compromised oxygen transport system secondary to myocardial infarction, chronic bronchitis aeb shortness of breath, dyspnea, and increased respirations during activities.
6) risk for infection r/t compromised host defenses secondary to respiratory infection. i should be specific on the respiratory infection shouldn't i?
7) risk for acute confusion r/t sleep deprivation
8) risk for constipation r/t diuretic use.
9) risk for self-care deficient r/t activity intolerance.
10) anxiety r/t shortness of breath aeb inability to sleep. i'm not sure if this makes sense to anyone else but me.
11) risk for sexual dysfunction r/t activity intolerance. can i use activity intolerance since it is a nursing diagnosis?
12) impaired social interaction r/t limited physical mobility aeb fatigue. again, not sure this one is proper.
head spinning yet??? mine sure is. i thought i was pretty good at writing these until i i was graded on my last careplan. i think i tend to get too creative at times and miss the boat.
thank you in advance for your time!

# 3- i didn't see a goal, to know if it's unrealistic or not

#4- chronic pain really isn't chronic in an acute diagnosis (mi)....or are you basing it only on the chronic bronchitis? if so, you need to have some numbers re: pain scale, and the goal of what is tolerable to the patient.

#6- already has an infection.... so risk is "done"- you're in "actual" territory

# 10- yeah, that one is a bit foggy.... usually the sob causes the anxiety- not vice versa....and inability to sleep usually isn't associated with sob- but could be an issue re: anxiety, and being so focused on getting to sleep...

otherwise, i think it looks reasonable :up: . but instructors are interesting creatures- lol.

the good news is that a lot of places now use "real language" and write care plans like : patient has pneumonia- and risk for activity intolerance. (the end) throw some interventions, the goal that there will be no complications (list a couple) by ______(date). and , poof= done!! school is where you have to do this stuff this way.