Desperately Need Help With Care Plans

Nursing Students Student Assist Nursing Q/A

Any help with care plans will be appreciated?

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.

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..

daytonite said:

The care plan concept is to assess the patient, analyze the abnormal data and determine what their nursing problems are and then to develop goals and interventions that are focused upon the abnormal data to:

  • improve the patient's condition
  • stabilize the patient's condition
  • support the deterioration of the patient's condition

I hope that is what you were referring to by working backwards! be aware that sometimes the patient's nursing problem can't be fixed. sometimes the best we can do is support the deterioration of the patient's condition, and that is ok.

That is exactly what i meant. I am used to having some actual 'abnormals' to evaluate to lead me to the nursing diagnosis. Thanks to this board i never made the common beginning error of thinking- this patient has copd, so they must be having some air exchange issues....

I knew to assess the patient and work off their abnormals to lead me to a diagnosis.

I am not used to "pretend your patient has otitis (not specified) and come up with 3 diagnoses and some interventions"

there are sooo many things that could need to be addressed there is no way to address them all.

Thanks for the links, I am on my way now to look further into symptoms to create a patients condition then redo the diagnosis.

I am trying to come up with a nursing care plan for a woman, SR, after an interview based on "Health-Perception/Health-Maintenance."

My patient has just recently been diagnosed with hyperparathyroid disease. She is complaining of pain in her bones (specifically her feet), inability to sleep/fatigue, headaches, "foggy thinking," and overall irritability.

My initial attempts at creating a PES nursing diagnoses are giving me serious trouble!

Here is what I have come up with: (and I need to select just ONE)

Impaired physical mobility related to pain and discomfort secondary to joint stiffness as evidenced by instability during performance of routine ADL.

Chronic pain related to joint stiffness as evidenced by client's self report of pain intensity of 8 on scale of 1 to 10.

OBVIOUSLY I am having trouble verbalizing these things. I know I cannot use HPT disease as part of my diagnoses.

I feel fairly confident in building my nursing nterventions and outcomes, but cannot come up with a proper diagnoses.

ANY suggestions would be GREATLY appreciated!

R

My goodness! Thank you for all the time and thought you put into your response! Very elucidating!

I've put a lot of work into this assignment since last night, and i think that i have a better grasp on the material. Your thorough explanation sure is helpful!

Yes, i would like to do something "about her headaches, inability to sleep, fatigue, "foggy thinking" or overall irritability." i am assuming these symptoms are related to the pain, though, no? If we alleviate her pain, won't her sleeping improve, thus decreasing her fatigue, headaches, and/or irritability? How would i incorporate these symptoms into only one nursing diagnoses (as the assignment dictates)? Is that possible?

Can't thank you enough! What a valuable resource you and this forum is!

Arg. Forgive me if I sent a duplicate. Computer is having trouble.

THANK YOU so much for all the time and thought you put in to this post!

I have spent a good deal of time on this assignment since my post, but definitely have not had the clarity I received from you!

Yes, yes I definitely want to do something about her symptoms of headache, fatigue, irritability, etc. How do I incorporate those symptoms into this ONE diagnosis (as dictated by my assignment)? Would they go under an additional diagnosis? Wouldn't alleviating her pain enable her to sleep and subsequently alleviate headaches, fatigue, irritability, etc?

THANK YOU again. What a valuable and incredibly knowledgeable resource you are!

Rm

Specializes in med/surg, telemetry, IV therapy, mgmt.
rlynn39 said:
Yes, i would like to do something "about her headaches, inability to sleep, fatigue, "foggy thinking" or overall irritability." I am assuming these symptoms are related to the pain, though, no? If we alleviate her pain, won't her sleeping improve, thus decreasing her fatigue, headaches, and/or irritability? How would I incorporate these symptoms into only one nursing diagnoses (as the assignment dictates)? Is that possible?

That's why i asked about them. Keep in mind that every diagnosis describes a problem and has a set of symptoms that characterizes it (as in defining characteristics).

  • Anxiety r/t physiological stress secondary to electrolyte imbalance aeb irritability, inability to sleep, and "foggy thinking".

The electrolyte imbalance is the calcium. It would be nice if there was some lab work to support that.

If her headaches are chronic, include them with the diagnosis for chronic pain. I wasn't sure when i was originally answering your question if they were related to the hyperparathyroidism or they were due to something else. If they are due to something else, you have to add that related factor to the diagnostic statement. If the headaches are something new, then the diagnosis for them should rightfully be acute pain.

I need help with care plan for a schizophrenic (disorganized type )and nephropathy, has history of swallowing metal objects . Have done care plans on med-surg patients , but never on mental illness .

Any info would help . Thanks

Specializes in Mother Baby & pre-hospital EMS.

I apologize if this was addressed earlier in this thread. I am working on my first care plan and had a question - on the template, it asks for the "Primary medical dx." If my patient had a diagnosis of "OA of the right hip" but had a "right total hip arthroplasty" performed (and was the reason for the pt being hospitalized), would the arthroplasty or the OA be the primary medical dx?

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