Desperately Need Help With Care Plans

[donsterRN, ASN, BSN]

Get a good care plan book! It's a lifesaver!

Some recommended care plan books:

I really like Nursing Diagnosis Reference Manual by Sparks & Taylor. Sparks & Taylor is the BEST one there is!!!! It follows ADPIE completely and has everything you could possibly think of

All-in-One Care Planning Resource by Mosby - care plans for med surg, pediatric, maternity, & psychiatric nursing

One program uses the book Cox’s Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s, Psychiatric, Geriatric, and Home Health Considerations, 5th Edition and it's wonderful! Everything is there, and it's very easy to use.

This "pocket-version" care plan book is short, simple, to the point, concise: Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales, by Doenges, Moorhouse, and Murr. Everything you need to know in a few short paragraphs at your fingertips.

[Jedi]

I hope everyone gets a kick out of this. I just finished a refresher course and had this great instructor who worked in ER for a long time. She told us certain things should always be in our daily plan of care for a patient and if they were you could not go wrong.

Someone else made an acronym of the points that goes like this:

S 'n' M Excites Frank!

Ha ha ha ha

Safety, Nutrition, Maslow's, Mobility, Elimination and Fluids

It's more like S 'n' M(squared) Excites Frank! Frank must be a pretty kinky guy! Can you tell that the nurse who made up the acronym had been a psych nurse for many years!

Anyway, from a practical point of view with nursing, it works. It gets the patient through the shift.

Safety is always priority, because if your patient isn't safe, then you will be writing an incident report and too many of those means you won't have a job and your patients are probably walking around with a lot of bumps and bruises.

Mobility is huge.

Even if a patient is bedridden (say a stroke patient), then you better be rolling them around to make sure they have good lung expansion on both sides. (ABC's!!) Think circulation when thinking mobility also, in regard to risk for blood clots (possibly another stroke, heart attack, DVT and PE- pulmonary embolism). Circulation again - in regard to potential bed sores. You may not see the damage to tissue, because it's happening below the surface. Next thing you know, whammo - decubs! Turn, use pillow logically and use the bed booties.

If the patient can be mobile, even up in a chair, then get them there as long as you have a doctor's order to do so. If you aren't sure because the patient just came in or they are getting weaker fast, then get that MD to order a physical therapy evaluation. Until then, have that patient turning. There are always those difficult calls, say an Alzheimer's patient who has a history of falls and is weak, but you don't want them to get weaker by keeping them in bed. The last clinical I had recently, the RN wanted the patient in a chair, so did I, the care assistant wanted a posey on that patient if they were going to be in a chair. I cringe at using restraints, but sometimes they are warranted. The doc knew the patient from the nursing home and ordered a posey while in the chair and an order for PT. Other option, get on the phone and have a family member stay with patient so they don't have to be posied. Now, you just have to see if they try to climb out of bed also and get an order for posey in bed if you have to. Ahhh! I hate restraints! It's a difficult balance, but I have to always remember that my shift is not the only shift of this patient's life. It's a collaborative effort, so do what is good for the patient now with future goals in mind. (In this case, PT).

Nutrition is very related to strength and diagnosis.

In the case above, you'd see how you need good calorie intake to keep a skinny little old man from becoming more weak. Then, what do you always need for old people? - If their diagnosis doesn't contraindicate it, fiber doesn't hurt to keep the bowels rumbling around. Mushed up food is not as palatable as regular food, so give it to them if they don't have any swallowing issues. (ABC's - A&B apply to people who can't eat well because of a stroke, no teeth, etc. Speech evaluation if you notice coughing. Don't want to give anyone an aspiration pneumonia!) Water is a part of nutrition that overlaps with fluids. Cleans your palate, and your mouth, prevents nasty infections in your mouth (along with teeth and gum cleaning in the morning), prevents dehydration and keeps the bowels rumbling once again! Do they need supplements. Is their neutrophil count low, (so they can't have fresh fruits, salads, and no flowers in the room because they are on reverse isolation). Do they need free H20 or juice (depending on their sodium level, are they vomiting or having diarrhea). Can they hold the fluids and food down. Do their bowels need a rest with a liquid diet (i.e, acute colitis). Do they have the gag reflex? Do we need to get their bowels woken up from anaesthesia by starting them on a clear liquid diet. If they need potassium, can you give it to them orally. If their potassium won't come up, do they need Magnesium? If they have asthma, do they respond to magnesium supplementation. How's the Calcium level? K+, magnesium and Calcium are all absorbed well in the gut. Their levels are all related and contribute to good muscle contraction and heart rhythms. Do they need low vitamin K, because they are on Coumadin. In this case, get a dietary consultation for patient teaching, give them a hand out and teach, quiz, etc.

Use your common sense and learn as much about nutrition as it applies to the particular diagnosis. You will learn a lot here and it very much relates to fluids (riders and electrolyte balance).

Maslow's always needs to be included. You need to see what level your patient is at and then get to that level with them so you understand how you will communicate with them, give them what they need and do your teaching appropriately.

Elimination is very related to mobility and nutrition and fluids.

How are they going to get to the bathroom? and getting there safely?, or do they need that commode or a bedpan. Think logistics and need for mobility tempered with safety and reality. They are not going to be in the hospital forever!

Are they eating enough to even make a bowel movement? (I hope so, if not, then that is the goal). Do they have enough fiber, oral fluids and mobility to keep them regular? Do they have a history of bowel obstructions? Look at their baseline, complications, patterns of output and goals.

Are they post-surgical. If so, do they have bowel sounds, gas, cramping? Have they urinated?, Is the suprapubic area hard, distended? Do they need to be straight-cathed to see if their kidneys are making urine output? Do they need fluids, are they 3rd spacing?

** I have learned how important 24 summaries of I's & 0's are! Review them. Learn their importance. This is a primary nursing responsibility. You are the first person to notice changes and should try to recognize situations where I&O problems are apt to happen so if they do, the problem gets moved on right away. It never hurts to have a doc review this if in doubt. You'll end up learning more when you ask the questions also. ***

Do you see how this all has moved very to Fluids?

- OK, be aware, I went off on this subject. Stick to the basics. Fluids are complex. It's good to poke your head in books, talk to the nephrologist, talk to the cardiologist, read about endocrinology. This is the cellular level of nursing and medicine, but there are also some basics to always remember and that's what goes into your care plans. Always know why they are getting fluid and why THAT PARTICULAR TYPE OF FLUID. Ask the doc if you can't figure it out. No use beating your head against the wall, right? We are here to learn and no one is a brainiac 24/7.

The part about care partners will not affect you until you start working. The stuff about SIADH, try to learn it at some point. The inter-relation between the endocrine system and fluids is very interesting and really comes into play in cancer and post-op patients. Learn about antidiuretic hormone at some point and understand its importance in fluid balance.)

Fluids include ORAL, G-tube, NG-tube, intravenous, intra-arterial, intraosseus, intrathecal.

Per my Med-Surg book, 2002 Ignatavicius and Workman, Med/Surg Nursing, Critical Thinking for Collaborative Care. . "These solutions and medications may be administered for therapeutic or diagnostic purposed, including the following:

• Replacement of fluid, electrolye, and nutrient losses
• Administration of anti-infectives
• Blood and blood product transfusions
• Administration of enhancing agents for diagnostic imaging

My notes from class say are more general:

1. Maintenance/ of daily fluid requirements

Learn the difference between crystalloids and colloids. Understand what isotonic, hypertonic and hypotonic is in terms of osmolality compared to the osmolality of plasma.

Memorize what kinds of fluids are isotonic, hypertonic and hypotonic.

Begin to understand what fluids are used in what situations (chronic and acute situations) and learn why.

Learn the different blood parts/products, when they are used and why they are used.

2. Replacement/ of loss of fluids - drains, insenisble loss, diarrhea, wounds, bleeding.

3. Treatment - used as a medium to deliver therapy, e.g. (K+, antibiotic, hyperalimentation.)

4. Diagnosis - used as a medium to deliver diagnostic dyes

5. Palliation - used as a medium to deliver pain medication, nutrition.

Do the 24 hour review of fluids. It is every nursing shift's responsibility. . Do not getting the habit of slacking in this area. Too many things are missed due to this and they can be things that are critical. If things look imbalanced, investigate why and ask yourself if the problem is being addressed. If it is not, then do what you can to correct a problem and/or notify a doc for further evaluation.

Just remember to think of what a typical patient that has same diagnosis would look like. If you don't know that, now is your time to find out, so look in your med/surg book. Then make sure your care plan addresses whether or not the patient is "balanced" fluid-wise or not. If yes, then you can always write done "potential for fluid and electrolyte imbalance" if that is a common problem for this type of patient. Then you just write - monitor labs results for electrolyte abnormalities and monitor I & 0's for imbalances (over or under hydrated), or you can write "take off orders for blood draws to monitor fluid and electrolyte status and make sure they get drawn and lab gives me a result. Report abnormalities, institute oral or IV therapy as appropriate or as ordered." Then or course, give every way you can do it orally before resorting to IV if oral is not contraindicated.

Here are some typical I & O situations:

Think about who is at risk for dehydration and why? Think about who is at risk for a fluid overload and why? Is the Na+ level high or low. If they are dehydrated, is it because they are putting out too much fluid or have diarrhea, or because they are not taking in enough fluid.

Their mental status and energy level is very affected by fluids. When was the last time you were hot and didn't drink water regularly for a few days. Did you feel like doing jumping jacks, doubtful.

If they are post-surgical, watch for adequate urine output and mental status changes. **Learn the dangers of D5W post-surgery and in general, how it can contribute to cellular swelling and increase intracranial pressure. Read some cases studies on this.**

Is there some kind of problem that affects them in which they cannot eat or drink (mental or phyical problem)? If so, when are the fluids going up. Watch the K+, Ca+ and Mag+ levels. Always remember that K+ is a drug - too much can make your heart stop. If a K+ rider is needed, best given through a large vein with a small gauge IV catheter to prevent pain at the IV site. If lidocaine is added, realize it can mask pain, so watch that IV site. Lidocaine is a drug too. Become aware of it's affects. If K+ needs to be given, can you do it orally or through a G-tube rather than through an IV. If the K+ level will no come up, get a Magnesium level. (K+ will not come up if Mag is too low). When will this happen? In patients with lots of watery diarrhea. Get a fecal incontinence bag on those patients. You need to know how much fluid they are losing in order to replace what they are losing AND give them their daily requirements.

Look at the output. Is it "sick" looking?

Diarrhea, bloody stool, steattorhea, solid as a rock, C. diff green and smelly, yuk.

Urine - is there enough? Is it smelly, is it concentrated? Does it have while blood cells in it? Is my patient eating any fruit (water content?), drinking, do they have good peri-care if that foley is in. If they have a suprapubic, is the site red, tender, distended? Is my patient so big, peri-care is difficult? If so, get however many it takes. Do they have to have that foley? Does my patient have a fever? Are they losing fluid in sweat, insensible losses. Do they need replacement fluid on top of that?

Lungs - does my patient have CHF? are they coughing? Do they have crackles or rhonchi? Make them cough. Does upper airway congestion clear? Does the crackling clear? Do they need some Lasix. Are they edemetous? Are they on fluids and getting overloaded?

These are the extras:

----- If a care tech isn't getting it done, tell them it is imparitive for care. Is this a problem for all the nurses? If so, maybe all the nurses need to bring this up at a meeting. If it's just one care tech for everyone, let the super know. If it's just that care tech with you, let them know that your nursing care needs to look good, if they are not being responsible and in doing so, make you look bad to the docs and your supervisor, let them know you're going to have to say something to someone because you can't put your job on the line. (You can't let negligence to duty go and letting it go makes you negligent and on the hook for it). If there is a legitimate excuse or you can estimate output, put something down rather than nothing, but put the reason why it is not exact. (Used the toilet before hat was given. Pt. took hat out of toilet.). Try to write down the number of voids at least. But don't completely guess at cc's and never make up anything! Let the next shift know exact I&O's weren't obtained and that you have told your partner you need exacts now. Write an order for strict I & O's if you can. Get a doctor to order it. Get those I's and O's going. always, if you empty something, record what you emptied and communicate it to the partner somehow, flowsheet is the best way. So many patients need I's and O's and considering how sick most patient's are, it's unusual, in my book to see someone who doesn't need them. (At least on a med/surg floor). The patient didn't just come in with nothing going on. If they were well enough, they'd be at home or somewhere else. If they can't be somewhere else, then things are out of whack.

--------------

**Learn about SIADH** Syndrome of Innappropriate ADH, watch for low Na+ levels. It is complicated, so take some time to undestand it and read some case studies. I had a patient with this and then his mental status went bad. He was taking Ambien at night, so I thought he was just tired in the morning, thought I'd let him wait to do that wash up. Nope, bad idea. He was actually becoming somnolent. When someone is falling asleep right in front of you mid-sentence, it's a problem. EKG showed heart block, we sent him to telemetry. By the way, his foley looked like a Mai Tai with Oxi-clean in it!) This guy had been on a fluid restriction the night before and had a 250cc bag of 3% saline up over the day prior. Not .3%, 3.0%. In the morning, I did notice that no one had taken the water pitcher out of his room. (That should have been a clue to me right away that the care was not on track. When I asked him about his fluid restriction, he told me no one had told me about it. Here's another clue.). This guy was a confabulater. He would tell me anything to make things seem OK and was not concerned about anything despite the fact that he had been in the hospital for days, hadn't eaten well for awhile and had cancer. Hmmm... something was wrong here. Yes... it was his mental status. Sometimes it's hard to get a grip on. When in doubt, ask your peers, a more senior nurse who has time to help, if not available, a supervisor, if not available, a doc. What did the nurse who gave you report say? Read the chart, when in doubt, call the doc. Sometimes you don't have time to figure things out on your own. Call the doc. Make sure you have an assessment to report before calling and let them know that you aren't sure if this is their baseline if that mental status has changed. Better safe than sorry. You do work for the patient, remember that. This guys was starting to have mental status changes due to cellular swelling in his brain. Yikes, that's a situation that deserves a monitors if not the ICU.

Remember, I'm a nurse with just 3 years of experience, or just 3 years of experience, however you want to look at it.

Geez - I better get off my butt and start working on my resume and looking for a job, eh?

Good luck. Hope I was helpful. (and not confusing. Things come with time. Just learn it as it applies for your care plans. Learn it like a lecture/class when you are in class and studying for tests.

??‍⚕️

[LPNstudent03275]

sylviamon said:

thank you for your response. i really appreciate it. what are the ABCs?

ABC'S: A=Airway, B=Breathing, C=Circulation. Assessing if they have a patent airway, are breathing, and do they have a pulse.

Good luck with the care plans. If depend a lot on my text books, internet, amd care plan books. I have to do weekly care plans for Med-Surg and then for clinical. Sometimes i hit the nail on the head and other times hit my finger.

Jenn

[cenote]

LVN2006 said:

any help?

I had a great teacher who told me to remember three things that should direct your care plan interventions. These are ASSESS, ASSIST, TEACH.

[VickyRN, MSN, DNP, RN]

truliblessed said:

HELP!!!!!!!! Trying to write first careplan

The patient has 2nd and 3rd degree burns and a left ankle fracture ,and a history of hypertension and diabetes. How do I prioritize. I was thinking maybe impaired mobility, and risk for infection.

Any suggestions, because I am completely lost and frustrated.

Prioritize according to ABC's and Maslow's Hierarchy.

Depends on how stable the patient is and when the 2nd and 3rd degree burns occurred. If he is a "fresh" burn patient, then airway and electrolyte imbalances take priority. Of course, pain issues also are priority throughout the course of care.

[trustsupplyguy]

Hepatic Encephalopathy is also known as coma resulting from liver damage. A high mortality rate is associated with this disorder, and the cause is unknown. (Source: Med Surge textbook).

Two major groups of signs and symptoms you'll be assessing for are neurological and respiratory (remember, the brain controls the respiration rate).

I'm going to assume your patient has lung sounds, let's say crackles, and a productive cough. This is your "as evidenced by".

So your nursing diagnosis is "Ineffective Airway Clearance related to depressed central nervous system function and dyspnea as evidenced by crackles and productive cough."

For goals, pick a measurable repiratory sign, like "O2 sat will remain above 90% during hospital stay" or "respiration rate will remain at 15 per minute throughout stay."

This gives your first two interventions: 1) monitor O2 sat Q2H; and 2) monitor respiration rate Q2H.

Now come up with as many more interventions as your teacher needs, mainly neuro or respiratory. Here's some for starters: elevate head of bead; auscultate for lung sounds; monitor for signs of dyspnea such as nasal flaring, use of acessory muscles, anxiey, & retractions; humidify and push fluids in order to thin secretions; assess pupil size and reaction; assess level of consciousness using Glascow coma scale; assess grip strength; assess reflexes. Of course you also want to assess for pain, administer meds, and check lab values too. You can teach deep breathing & coughing, and also explain why you are doing the assessments you are. Explain something about the pt's medications.

That should get you started. Other good diagnoses might be Activity Intolerance (cardiovascular deconditioning), Impaired Skin or Tissue Integrity (pressure sores from decreased mobility and bed rest), or Constipation (lack of motility due to inactivity or medications).

Good luck!

[neneRN, BSN, RN]

Well, you've got your nursing diagnosis; Impaired Skin Integrity, so next you need your "Related to," which will be specific to your pt, but some common ones are physical immobilization, mechanical factors (pressure, restraint,injury, surgery,etc), altered nutritional state (obesity or emaciation), alterations in turgor (edema), or skeletal prominence.

For your "as evidenced by," you'll use your assessment findings, i.e, does your pt have a wound, pain, itching, numbness, etc.

Next, your "desired outcomes," which would be how the pts diagnosis should show improvement, i.e., wound displaying signs of healing, pt participating in treatment plan, etc.

"Actions/interventions" are going to be your ongoing assessments; ex are identifying underlying condition/pathology, noting changes in wound, determining depth of injury, evidence of infection, evaluating risks for further injury, using appropriate dressings, repositioning schedule, encouraging mobilization, teaching.

So if your problem is a pressure ulcer, your care plan may look something like this;

Impaired skin integrity related to physical immobilization, pressure, and skeletal prominence as evidenced by open purulent wound to coccyx.

Desired outcome:

Pt will be free of purulent drainage within 48 hours. Will display signs of wound healing with wound edges clean/pink within 60 hours. Will participate in prevention measures and treatment program.

Actions/Interventions:

Assess wound with each dressing change (rationale:provides information about effectiveness of therapy and identifies needs)

Obtain culture of wound on admission (rationale; to identify pathogens and therapy of choice)

Administer ordered antibiotic (rationale:treatment of infection)

(And on and on, there are all kinds of actions/interventions for skin integrity, and this is usually the longest part of the care plan.)

I'm sure others can add to this, I haven't done a care plan since I was in school 5 years ago, but these are the basics that I remember.

[RNin2007]

Here is a sample of the last care plan I turned in. The first page is the "example" and the following pages show the 3 nursing diagnosis I chose, and the interventions/rationales that I included. Hope this helps.

The patient that I took care of this day had extensive facial lacerations, but was otherwise healthy...no other problems, and was ready to go home.

careplanSAMPLEj.doc

[rpv_rn]

1. Collect your patient data, including subjective (what pt states) and objective (what you see). In texts - they may be called "defining characteristics."
   
2. Cluster those data & see the related factors causing #1 (i.e. medical diagnosis, pathophysiology, current health status).
   
3. Look at reference for nursing diagnosis which has your defining characteristics & related factors.
   
4. State your goal / patient outcome with measurable evidence (what do you want patient to demonstrate or verbalize and when is a realistic time frame to accomplish this patient outcome). This is focused on patient's behavior, not the nurse's behavior.
   
5. Interventions. What will you (the nurse) perform that will address the patient data and lead to the patient outcome.
   
6. Evaluation. Look at your goal / patient outcome / measurable evidence. Did you meet the criteria? If yes, then outcome met. If no, look at interventions that need revision.

• Hope this helps.

[Daytonite, BSN, RN]

Sorry to be answering so late. I've been on vacation.

Care plans are a puzzle at first. Since i was in school back in the early 70's i also happen to think that nursing diagnosis also just muddled up the whole thing as well, but that is my own personal opinion since i was "raised" on doing care plans another way which i think is much easier. I back into my nursing diagnoses.

In my initial nursing school days, a care plan started off listing "problems" rather than "nursing diagnosis". A problem was very easily a symptom, a sign, either existing or having the potential to exist. We would list them as things like nausea, vomiting, diarrhea, elevated white cell counts, abnormal chest x-ray, fever, insomnia, falls easily. Today, those are all turned into nursing diagnoses. However, the process to get to that is the same. Nursing diagnosis is just forcing you to look at the entire picture of what is going on with the patient. So, all that "data" that rpv_rn lists as your first order of business is necessary. You need to scrutinize the patient's chart. You want to get information from the following parts of the chart: lab, x-ray, admission history and physical, er report (if there is one), any operative reports and the doctor's progress reports. You should also make a chronological list of the doctor's orders starting from admission to the current day. From that you should be able to put together a list of current medications and iv fluid orders. From the nurses notes you can get information on the vital signs. You can check the medication record for information on prn medications that were given. From the nursing admissioin assessment you will find information on the patient's ability to handle his day to day care and what he may or may not need assistance with.

From the doctor's history and physical, his progress notes, and some of the lab and x-rays you should be able to get a pretty good idea of what the patient's medical diagnoses are. Sometimes the doctor himself won't know what the diagnosis is and is only working from the patient's symptoms. As will you. If you have a medical diagnosis to work with, then that is where you go in your nursing textbook. Look at the pathophysiology of the disease. List the symptoms. Is your patient exhibiting any of them? Look at what your textbook says about how the disease is diagnosed. Have any or all of those tests been done for your patient? What may be need to be done yet? Are there any special preparation for them that you as the nurse will need to make sure are done? What are the medication and treatments normally ordered for the disease? Compare those to what have already been ordered for your patient. The doctor may have indicated in his progress notes why some medications or treatments were or were not ordered. Remember that every patient is unique just as much as they also fit the mold of a disease.

Now, look at your list of doctor's orders and compare them to what you have read in your textbook. What orders are there that don't seem to match what was in the textbook? You'll need to investigate why the doctor ordered those things. There was a reason. Perhaps there is some other pre-existing condition that just didn't get mentioned in the history and physical. It may or may not be something that will turn out to be important to the care of the patient. Maybe the patient is having a symptom that is being treated that doesn't yet match a specific disease.

Each of the treatments or tests ordered by the doctor require some kind of nursing intervention. Those begin to form your list of nursing actions. There are many other nursing actions you can find to do for your patients as well. Look at how your patient is able to get through his activities of daily living. This involves things like eating, toileting, bathing, dressing, ambulating, interacting with others, sleeping. What independent actions as a nurse can you take to help him with these? For instance, if your patient is npo (that is a doctor's order) and on iv fluids (another doctor's order) you are going to list nursing actions that address making sure that no oral food or fluid goes in to that patient and that the iv is patent and all the actions involved in maintaining and managing the iv. Those are independent nursing actions. Some are dictated by hospital policies; some by nursing principles. However, you can also do some things to help with the dry mouth and lips that do not involve getting a doctor's order. Intake and output may need to be kept even though the doctor didn't order it.

Is this making any kind of sense to you now? It all forms a big connected picture. It is all rational. Every doctor's order is based on the treatment of a disease or symptom which in turn can be traced to the pathophysiology of what is going wrong with the patient's organ. Everything the nurse is doing is connected to the doctor's orders and helping return the patient to some level of normalcy or to the assistance of the adls of the patient.

Quite honestly, goals and outcomes are difficult for me to write. Theoretically, they should be the easiest. They are simply the opposite of the problem, right? You just need to tack a time element on to them.

I'm listing some links to care plans that you can look at. The ones at rn central are kind of short and abbreviated, the kind we used to do in the nursing homes and on real busy nursing units. However, they give you an idea of what is going on with a care plan. When you finish a care plan on a patient you should have learned something about their medical problem, it's treatment and the nursing care they should receive. Good luck with your beginning efforts.

https://www.rncentral.com/nursing-library/careplans/

[Daytonite, BSN, RN]

capecoralchick said:

Hi everyone, I just wanted to thank you all again for the help. This is my first care plan. Quick version: a 20 yr old in traction for 3 weeks on bedrest.

My first diagnosis is impaired tissue integrity/ or would skin sound better.

I was wondering if related to surgical procedure is ok??

And aeb- presence of incision..... (I'm confused on what manifestations i should use for a surgical incision)

I just really need to get a good understanding. I'm going to sit down with some books tonight after I put my baby to bed.

First order of business in developing a care plan is to assemble the data that you collected on the patient. You are going to be most interested in the abnormal data for developing a care plan. If you've assessed the patient using maslow, gordons functional health patterns, roper/logan/tierney's activities of living or some other listing your instructors have given you, you are going to find those abnormal data items there. So, from a nursing point of view, what are this patient's symptoms (abnormal data)? Does he/she have any of these: pain, constipation, skin breakdown, self-care deficits such as difficulty with eating, bathing, toileting, or dressing?

You want to take these patient's symptoms and put them on a list. Start looking to see if any of them kind of stick out as kind of belonging together to form a problem the patient is having that you, the nurse, can treat.

Using impaired tissue integrity

For example, if the patient has several reddened bony prominences where pieces and parts of his/her body is contacting the mattress, then you have the evidence to support a nursing diagnosis of impaired tissue integrity.

Your "related to" part of your diagnostic statement has to do with what is causing the symptoms. So, is the reddened skin due to:

• mechanical factors such as pressure, shearing forces or friction
• nutritional deficits
• chemical irritants (docy excretions, secretions, medications)
• impaired physical mobility
• altered circulation
• a fluid deficit or excess

The above items can be used as "related to" factors with impaired tissue integrity. Now, just think about this a minute. How is a surgical procedure the cause of the patient's impaired tissue integrity? The nanda definition of this particular diagnosis is: damage to mucus membrane, corneal, integumentary or subcutaneous tissues. To my way of thinking, an incision is a medical intervention and treatment, not damage. In actuality, this particular diagnosis is more appropriately used for stasis ulcers or damage to skin that occurs from bedrest, lying on tubes or other medical devices. There is another diagnosis to cover the incision that will be more appropriate.

Moving on. . .

What is your physical assessment of this patient's incision? Are there any signs or symptoms of infection? If so, what are they? If he has a temperature, there is a nursing diagnosis to cover that. If not, you can still use the nursing diagnosis of risk for infection. That is always an appropriate nursing diagnosis to use with a newly post-op surgical patient.

Once you know what your patient's symptoms are and have them all appropriate grouped under the correct nursing diagnoses, your next step is to develop nursing interventions for each of the symptoms. That part is really not the hard part since you can readily find nursing interventions in your nursing textbooks. What you are stuck with is the nursing diagnosis and the nursing diagnosis statement.

Here are possible nursing diagnoses that would be related to a patient in traction. Does any of your assessment data look like it might fit into any of these diagnostic categories?

• Acute pain r/t immobility, injury or disease aeb (your assessment data)
• Constipation r/t immobility aeb (your assessment data)
• Impaired physical mobility r/t imposed bedrest aeb traction
• Ineffective breathing pattern r/t inability to deep breath in supine position aeb (your assessment data: decreased, diminished respirations or other signs of struggling to breath) note: pulmonary embolism is always a risk factor in bedrest patients!
• Ineffective tissue perfusion r/t interruption of venous flow aeb (your assessment data: edema, weak pulses, skin color or temperature changes in the elevated extremity, altered sensations, cold extremity)
• Self-care deficit: feeding, dressing/grooming, bathing/hygiene, toileting r/t degree of impaired physical mobility or body area affected by traction aeb (your assessment data)
• Powerlessness r/t forced immobility in health care environment aeb (your assessment data: fluctuating behavrior, nonparticipation in care, anger, passivity, irritability, fear of alienation, expressions of frustrations because of inability to perform adls or of having no control over care)
• Risk for impaired skin integrity r/t contact of traction equipment with the skin aeb (your assessment data)
• Risk for disuse syndrome r/t mechanical immobilization aeb (your assessment data)
• Impaired transfer ability r/t presence of traction aeb (your assessment data)
  risk for infection r/t invasive procedure [surgery] aeb (your assessment data: environmental exposure to pathogens, immunosuppression, malnutrition, suppressed inflammatory response, chronic disease)

Since this is a first care plan and a surgical orthopedic patient as well, go with the most obvious and important things. Are you allowed to use potential nursing diagnoses, the ones that begin with the words "risk"? If so, this is the way and order of priority i would go. Remember, i really don't know this patient like you do. I am basing this on my years of experience in nursing, but i'm sure i've given you a great deal to think about!

1. Acute pain r/t immobility, injury or disease aeb (your assessment data)
2. Self-care deficit: feeding, dressing/grooming, bathing/hygiene, toileting r/t degree of impaired physical mobility or body area affected by traction aeb (your assessment data)
3. Constipation r/t immobility aeb (your assessment data)
4. Risk for infection r/t invasive procedure [surgery] aeb (your assessment data: environmental exposure to pathogens, immunosuppression, malnutrition, suppressed inflammatory response, chronic disease)
5. Risk for impaired skin integrity r/t contact of traction equipment with the skin aeb (your assessment data)

Post any other questions you have with the construction of this careplan to this thread. I will keep my eye open and hope my telephone line (I only have a dial up connection) is being cooperative today. Others are encouraged to chime in here as well.

[Daytonite, BSN, RN]

The first thing you need to do before you assign any nursing diagnosis is to organize your abnormal data. I made a list of the data you listed and then organized it into what i felt were groupings that fit together. Then, i started looking at what nursing diagnoses fitted those "symptoms" and this is what i've come up with in the order of priority i would list them (maslow). My first three diagnoses are all on maslow's physiological needs. The second two are safety need. If you decide to use any self-care deficit diagnoses or the impaired mobility diagnosis they fit under physiological needs but below the ineffective protection diagnosis. I also included the medication information you provided and matched it to the medical diagnosis information you gave. I've added a couple of notations in red where i think you either need to add some data you may have forgotten to include because you might not have been thinking that it was important or to give you my thinking. However, you need data to support your nursing diagnosis. Just like a runny nose, fever and cough get a medical diagnosis of a cold, every nursing diagnosis also has defining symptoms that must meet the criteria to enable you to use that particular nursing diagnosis.

Decreased cardiac output r/t altered electrical conduction aeb

• hypertension 147/83 bilat.
• metoprolol [for hypertension]
• weak pedal pulses
• digoxin [cardiac gycoside, antidysthythmic]
• diltaziem [calcium channel blocker, for angina, hypertension, afib]
• simvastatin [antilipidemic]
• asprin [antiplatelet, anti-inflammatory, analgesic]

Impaired skin integrity r/t mechanical factors (i base this on the rhabdomyolysis. I assume this man fell and was lying on the affected leg and forearm for some length of time before he was found. However, if you have documentation to back up altered circulation, altered turgor or altered fluid status you can use those as "related to" factors as well.) aeb (see list directly below)

• stage 2 blister on coccyx - red, blanching, 1" x 2"
• right forearm from elbow to wrist is bruised 85%.
• right medial thigh near knee has redness and bruising (ecchymosis) of 5" x 4"
• right lateral thigh near knee has redness and bruising (ecchymosis) of 7" x 9"

Ineffective protection r/t infection [you need to specify the kind of infection if you are allowed to use medical diagnoses in this area of the diagnostic statement] aeb [any other symptoms such as fever, purulent drainage, etc.]

• elevated wbc (from uti)
• levofloxacin [antiinfective] - being given for an infection, where? urine? muscle?

Risk for deficient fluid volume r/t reduced blood flow to kidneys [this is because of the rhabdomyolysis causing a strain on the kidneys] aeb

• high bun (35 on admit now 39)
• creatinine (1.3 on admit, now 1.6)
• tachycardia of 117, irregular

Risk for falls r/t history of falls (don't need an aeb with a "risk for" diagnosis)

• Generalized weakness

Your items (1) rr 18 & not deep or shallow, and (2) i/o is 3000:3100, iv fluids running @ 125 are normal data items. However, the i&o and iv fluids while not necessarily being symptoms, fit as evaluation items with the nursing intervention items under the risk for deficient fluid volume diagnosis.

To use the impaired mobility diagnosis you need to have some supporting data. You have generalized weakness which you can use as the "related to" factor. Is there any other "related to" factors? Also, there are three specific types of impaired mobility according to nanda: bed, physical and wheelchair. So, you have to be more specific when you write that diagnosis. You need data like inability to turn from side to side, limited range of motion, decreased reaction times, slow movements, that sort of thing.

As far as using any of the self-care deficit (impaired ability to perform or complete activities) diagnoses (bathing/hygiene, dressing/grooming, feeding, toileting) again you need to have the supporting data, the inability of the patient to do these things. Generalized weakness (and, yes, you can use this as a "related to" factor in multiple diagnoses), lack of motivation, impaired mobility, and perceptual impairment are all "related to" factors that can be used for the self-care deficits.

I suggest you use either self-care deficit or impaired mobility, but not both. Your care plan will run on and on and start to get repetitious between those two.

Ineffective tissue perfusion is due to a decrease in oxygen resulting in the failure to nourish the tissues at a capillary level. Usually you are looking at chronic changes in the patient that are causing these conditions. With your patient, his rhabdomyolysis is the result of injury and will heal so the impaired skin integrity would be the appropriate diagnosis to use. I know he also has pvd, but you really have given no data supporting the pvd (edema, altered skin characteristics, skin discoloration, altered sensations, diminished arterial pulsations, pale skin color upon elevation of the extremity with color not returning upon lowering the leg). If you have that data, then go for it.

Last step is writing goals, outcomes and nursing interventions that you base on your aebs. You simply take each of the data items or symptoms you have to support each diagnosis and write nursing interventions for each of them.

Hope that gives you some direction. Please don't feel obligated to use the information exactly as i have given it to you. After all, you know the patient better than i do. Your instructors have given you "rules" to use that i am not privy to, and by all means make sure you follow their "rules". I'm working from what you wrote and what i've seen in my years of practice. And, please, don't let others scare you about decreased cardiac output. I think that because it covers such a broad range of cardiac symptoms from simple all the way to involved icu stuff that people get scared of it. To me, it covers a ton of stuff. You can go in so many directions with that diagnosis but it's all based on your patient's symptoms. Always look at your data and break your data down to as simple terms as you can get. What i think confuses people is the difference between "related to" and "aeb" items are. There is some crossover between these items in the cardiac output diagnosis. You always have the doctor's medical diagnoses to help guide and cheat with a little.

Go get 'em, angela! i expect to hear that you get a terrific grade on this care plan!