Desperately Need Help With Care Plans

Any help with care plans will be appreciated?

Specializes in Med/Surg, Tele, IM, OB/GYN, neuro, GI.
homieboi said:
i was asked to do NCP's for pneumonia even without a patient. So any NCP's for pneumonia will do. Thankz in advance.

OH. I don't have one but if you have or can get your hands on a care plan book there should be some in there.

Thankz Tampagirl... but if somebody has or have NCP's of Pneumonia can u post it here.. thankz...

Specializes in Emergency Room.

When doing your care plans, always the priority one's should be addressing the pt's. physiological needs, then address their psychosoical needs (EX. knowledge defecit, anxiety, and so on).

Also when doing your outcomes, always make sure they are measurable.

-Pt. will maintain adequate oxygention throughout shift as evidence by: skin warm and pink, Oxygen saturation > 90%, PaO2 between 80-100, no shortness of breath, no cyanosis, etc.........

Hope this helps, I know when I was just starting nursing school, care plans were an entire new language. Feel free to message me if you have any further questions.

Specializes in Emergency Room.
hm3 s. collins, spn said:

I have a pt admitted for interstitial pneumonia, and has anemia- low h&h and metastatic cancer of unknown origin, he has low prealbumin, protein malnutrition, hyponatremia, crackles in rll, inspiratory wheezes in rul, lul, and lll. He is on 12l o2 nc and has a o2 sat of 90-93%.

I have some nursing dx's thought of but not sure about the r/t part and which ones to use and in which order I need 3.

Impaired gas exchange - what is the r/t part that I should include ?

Ineffective airway clearance- what is the r/t?

Imbalanced nutrition less than body requirements- what is the r/t part? The man has a normal bmi but has protein malnutrition!

Deficient knowledge r/t ? Aeb pt asking why he is on steroids,

Activity intolerance r/t ?

Chronic pain is r/t chronic disease process okay? He has met ca in his bones- high wbc, low rbc, low h&h barely low na+, and slightly high glucose- non fasting.

Can I use infection as a nursing dx or only risk for infection?

Any help would be greatly appreciated!

Okay, don't get too stressed here! This is an easy one. If you learn anything from nursing school, please let it be airway breathing circulation!!!!!! I can't emphasize that enough. This applies to everything you do, assessment, care plans, prioritizing care, prioritizing which pt. To see first, test questions, and even your interventions.

You're on the right track, you just have to trust your intuition here. By what you have here I would go in this direction.....

#1 ineffective airway clearance (remember airway!:nmbrn:) r/t unable to remove secrections effectively

#2 impaired gas exchange r/t the secretitions

#3 imblanced nutrition: less than body requirements

#4 what about an infection diagnosis? The pt. Does have an elevated wbc, what about his temp? Was it high as well??? Go with the infection diagnosis here.

#5 chronic pain r/t disease processes

I also noticed that your pt. Is on 12 liters of o2 per nasal canula. That is way too much. It sounds like to me that he needs to be on a non-rebreather mask. His sat's should be much higher than that, with that much oxygen. You really have to be careful with administering oxygen, you can cause oxygen intoxication in some pts., especially ones with copd. What about his abg's, did he have any? That will tell you if this pt. Is compensating for his defecit. Also, a slightly high fasting glucose is normal in someone that has an infection. It is the body's natural way to react to an insult.

I hope this helps, if you have any other questions please feel free to message me. I try to answer messages as soon as I can. Stay with it, it will come to you, just takes some practice.

I have a patient a 63 years old woman conscious, coherent, cold and clammy, with a temperature of 95 deg.F. She had a foley catheter in place with concentrated urine of 25cc per hour, and an IV of 5% dextrose in water. Her lips were cracked and her skin was dry and scaling. She has a pneumonia and she had already been in the hospital for 9 days. She also refused to eat for the past 2 days and had not a bowel movement for 5 days. Can somebody help me to make a Nursing Care Plan for this problem? I'm really having a hard time to make a NCP for this one. Thanks.

Specializes in NICU.
homieboi said:
I have a patient a 63 years old woman conscious, coherent, cold and clammy, with a temperature of 95 deg.F. She had a foley catheter in place with concentrated urine of 25cc per hour, and an IV of 5% dextrose in water. Her lips were cracked and her skin was dry and scaling. She has a pneumonia and she had already been in the hospital for 9 days. She also refused to eat for the past 2 days and had not a bowel movement for 5 days. Can somebody help me to make a Nursing Care Plan for this problem? I'm really having a hard time to make a NCP for this one. Thanks.

To do a care plan you must start with a nursing diagnosis. What about constipation, risk for immobility (or actual?), risk for fatigue (or actual?), ineffective airway clearance r/t increased respiratory secretions s/t pneumonia, risk for infection (dry skin, immobility, decreased urine output, foley, pneumonia, poor diet...), imbalanced nutrition: less than body requirements, risk for impaired skin integrity. Once you decide on an appropriate diagnosis, you can then develop a care plan tailored to your patients needs. Do you have a care plan book or a Nursing Diagnosis book? Those help out a lot!

I have this patient in ICU a male 41 years old. He is comatose GCS3. His diagnosis is acute respiratory failure with subdural hematoma secondary to fall. So i'm in charge of him and i got 35 degrees celcius actually his temperature doesn't go up in 35 above when i look at my thermometer. And he also got a BP of 80/60 mmHg. He is with endotracheal tube connected to mechanical ventilator and with the following settings of FI02 50% TV 450 BUR 14 AC MODE. I was asked to make 3 NPCs. Im thinking to use hypothermia, ineffective breathing pattern, and hypotension but i can't use hypotension as my diagnosis. Can anybody help me to make my 3 diagnosis a proper one? i really appreciate anyone's help. DAYTONITE can you help me again? Thank you and God bless.

Specializes in med/surg, telemetry, IV therapy, mgmt.
homieboi said:
I have this patient in icu a male 41 years old. He is comatose gcs3. His diagnosis is acute respiratory failure with subdural hematoma secondary to fall. So I'm in charge of him and I got 35 degrees celcius actually his temperature doesn't go up in 35 above when I look at my thermometer. And he also got a bp of 80/60 mmhg. He is with endotracheal tube connected to mechanical ventilator and with the following settings of fi02 50% tv 450 bur 14 ac mode. I was asked to make 3 npcs. Im thinking to use hypothermia, ineffective breathing pattern, and hypotension but I can't use hypotension as my diagnosis. Can anybody help me to make my 3 diagnosis a proper one? I really appreciate anyone's help. Daytonite can you help me again? Thank you and god bless.

Nursing diagnoses have to be based upon the abnormal assessment data that you have collected on the patient. I suspect that there is more abnormal data than what you have posted. If you have diagnosed this patient with ineffective breathing pattern then he must have some of the symptoms of it, but you haven't listed any of them. Is he needing to be suctioned? There is a diagnosis that deals with an obstructed airway--ineffective airway clearance. This patient is comatose. How are his adls being met? There are many self-care deficits here. Is he being turned? A patient in a coma is always in jeopardy of getting pressure ulcers. There is a nursing diagnosis for that--risk for impaired skin integrity. How is the patient's nutrition being taken care of? Think about all the different things that are being done for this patient. They all can be classified as part of the problems that the patient has. You need to do a thorough assessment of this patient's nursing needs by adl (bathing, dressing, physical movement, eating, elimination, grooming) rather than focus on his medical diagnoses and the nursing problems (nursing diagnoses) will become more apparent. The adls that a patient needs assistance with or can't perform by themselves at all are patient problems that need to become part of the care plan. We are nurses and treat the patient's nursing problems, not his medical problems. In the icu the nurses can only do so much with the patient's respiratory and cardiac status and much of it is based on orders from the doctors.

My patient is being turned from time to time. He is being suctioned by the nurse on duty with whitish sticky phlegm secretions. Oral care also been given. He no longer response to pain and light. He have a harsh breath sounds. Temp= 35ºc P=119 R=25 BP=80/60mmHg. He had a score of GCS3. He is not capable in doing his ADL so the nursing aide does it for him. But can i use the hypothermia and the hypotension? i really can't think of something else. Daytonite what can you suggest to me? thank you again.

Specializes in med/surg, telemetry, IV therapy, mgmt.
homieboi said:
can i use the hypothermia and the hypotension? i really can't think of something else.

Yes, you can use the hypothermia. No, I don't see how you can use the hypotension. I gave you two other possible diagnoses to use. That's all I can suggest based on the information you provided.

thank you DAYTONITE..

Yup, I got the careplan concept mastered.... Piece of cake....review patients problems- check,

Work backwards- check.

I was quite proud of myself.. Now comes the wrench.

I need to do nursing diagnosis and interventions on an imaginary pediatric patient with otitis and one with tonsillitis. I need 3 for each disease. I froze up and went blank, this is HARD. I have no m/b or AEB cuz there is no patient. 20 months of doing this based on what I am seeing, now I need to fake it??!! I LOVE nursing school! LOL

Anyway, I tried to be thoughtful, and I did not want to pull the 2 out of the book that I know most people in the class will use. We needed 3 FULL diagnoses with the r/t and m/b. Then we needed goals and interventions...

I muddled through tonsillitis, and for otitis I came up with:

1- Acute Pain R/T infectious disease process M/B patient complaints of pain in both ears (this is a gimme)

2- Anxiety, mild r/t hospitalization m/b decreased pulse and sleep disturbance.

3- Disturbed Sensory Perception: Auditory, r/t chronic otitis, m/b head tilting, pt cups ears with hands, pt cannot walk straight and states his “head is spinning”, pt states his ear hurts.

Be gentle, I know I do not have exact things like "pain is 8/10" but the instructor said to be real generic and include things that COULD be a symptom. This is what is throwing me for a loop. I cannot do a pretend person! LOL

Will these suffice? And if you have advice for interventions for the disturbed sensory perception I would love to hear them.

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