Desperately Need Help With Care Plans

Any help with care plans will be appreciated?

Specializes in med/surg, telemetry, IV therapy, mgmt.

Kelly, you are almost there. You actually have all the information you need-->a patient with a medical diagnosis so you can look up the signs and symptoms of that disease or medical condition in order to determine their nursing problems.

Your two patients have otitis (did they specify which type of otitis?) and tonsillitis. You need to look up the signs and symptoms of these two medical conditions and how the doctors diagnose and treat them. From that information you abstract how we nurses are going to deal with the situation. Many of the signs and symptoms of these conditions are the same signs and symptoms that we would also pick up when we do our assessment at the patient. You can also "imagine" what adl problems might be involved.

Some time ago I posted a whole bunch of websites to help students find information about...

I would suggest that after looking at the s/s and medical treatment of these conditions that you will find different nursing problems of a higher priority than anxiety, especially in a child. Children handle separation from their parents differently than adults, if they need to be hospitalized. They also have magical thinking about what happens during hospitalization or surgery, so their teaching needs are approached differently from adults.

By the way, 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.

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 med/surg, telemetry, IV therapy, mgmt.
bailey88 said:
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

All care planning begins with doing a thorough assessment of the patient. assessment includes:

  • Collecting data from medical record
  • Doing a physical assessment of the patient
  • Assessing adl's
  • Looking up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology--in this instance you need to look up information about
    • schizophrenia
    • nephropathy
    • ingestion of foreign objects

You want to isolate and make a list of the abnormal data that you discover during your assessment. That list of abnormal data is what you use to

  • Choose nursing diagnoses
    • determine goals
    • develop nursing interventions
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?

Specializes in med/surg, telemetry, IV therapy, mgmt.
Sehsun said:
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?

The primary medical diagnosis is the "OA of the right hip". The arthroplasty is a medical procedure.

Hi , I just want to know if am on the righttrack. I have a 75 year old male pt with hematuria and urinary retention. He is on a continuous bloody irrigation foley with normal saline , his H&H have been low and he had a blood transfusion yesterday because of his low blood rbc and h& h. he has a hx of hypertension and diabetes. I am looking at risk for injury and altered tissue perfusion renal. am i on the right track, thanks

LVN2006 said:
any help?

Can u please help me in doing my nursing diagnosis? My assessment are + dyspnea, pale, restlessness, RR 30... I need a diagnosis using PES problem, etiology, s/s...

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