Careplan

[L.A.W]

HELLO,

Ok this patient had a lot going on and im having problems bringing the Dx all together.HELP!!!!

DX:PNEUMONIA

Admission Dx: Fever R/O Sepsis

Past Medical History

1.COPD

2.Diabetes Mellitus

3.Hepatitis C

4.HIV

5.HTN

I have to come up with 4 Dx. I did not know if I should add her past history in her most recent Dx.

Symptoms:

1.S.O.B (Shortness of Breath) (external and at rest)

2.Fever(102)

3.Cough

4.Chest Pain

Objective:

Temp:102 RR:22 Pulse:108 BP 118/74

Breath sounds are decreased in righ sid of lungs (maybe from inflammation)

a Few crackles on her left side.

I know I want to work with Airway, Chest Pain ,and something with Sepsis

Resp-Fluid Volume Deficient,Resp-Impaired Gas Exchange,risk infection,acute pain,activity intolerance

[Daytonite, BSN, RN]

Once you have completed your assessment of the patient, the next task is to list the abnormal data. That data is the symptoms of the patient's nursing problems. What you have to do is determine what those nursing problems are and put names (nursing diagnoses) on them. Using a nursing diagnosis reference would be helpful because it will contain defining characteristics (symptoms) for all the different nursing diagnoses. I know you are looking for someone to give you those diagnoses, but you will learn more by searching and finding them on your own. You are not far off with the diagnoses you are thinking of. However, based on the list of symptoms you posted I can tell you that you do not have the symptoms for Deficient Fluid Volume, Impaired Gas Exchange or Activity Intolerance and there is 2 actual nursing problems (nursing diagnoses) that you totally missed.

• S.O.B (Shortness of Breath) (external and at rest)
  
• Breath sounds are decreased in right side of lungs
  
• a Few crackles on her left side
  
• Cough
  
• RR:22
  
• Fever(102)
  
• Temp:102
  
• Pulse:108
  
• Chest Pain
  

[L.A.W]

I do not want you to spoon feed me I just would like help to make sure I am going in the right direction its hard putting it all together. Ok so you said togo by the symptoms and find Dx. So with the first one S.O.B. Airway is a main priority.Would it be correct to go with Ineffective Breathing Pattern r/t inflammation process a.e.b right lung absent sounds?

[Daytonite, BSN, RN]

I suppose. But that was not the diagnosis I was thinking of. You are totally ignoring the cough and crackles in the lungs.

[L.A.W]

for the crackes and couging would it be ok to combine them both in one Ds?

Ineffective Airway Clearance r/t retained secretions a.e.b diminished breath sounds,crackles upon ausculation of lungs,and persistant coughing.

[Daytonite, BSN, RN]

for the crackes and couging would it be ok to combine them both in one Ds?

Ineffective Airway Clearance r/t retained secretions a.e.b diminished breath sounds,crackles upon ausculation of lungs,and persistant coughing.

Yes. Now address the fever.

[L.A.W]

Thanks so much.you are so much help especially when no one has actually explained to you how to do it. For fever I was thiinking about going with Hyperthermia r/t inflammatory process a.e.b fever of 102????

[Daytonite, BSN, RN]

That is correct.

[L.A.W]

I think I'm pretty much set.I'm learning I'll have to just find these Dx's in my careplan book for the interventions and rationals and ill hopefully pass this NCP

[Daytonite, BSN, RN]

please read the early posts on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. the process of diagnosing for nursing is no different than what doctors, car mechanics or plumbers do. however, we have the nanda taxonomy which is a listing of the 206 nursing diagnoses that includes their signs and symptoms as well as some of their causes (nanda international nursing diagnoses: definitions and classifications 2009-2011). you need to have access to this information. diagnosing is not guesswork. it is rational thinking. however, you have to do the preliminary work first. that is done when you take care of the patient. what you see, hear and observe; what you read in the chart. all the information is important information that you need to consider when you sit down to write your care plan.