Desperately Need Help With Care Plans

Any help with care plans will be appreciated?

[lildscalf]

No bubble baths or douches-it changes the nayural flora of the lady parts

If repeated cases of UTIs explain that intercourse can cause an infection and to urinate afterwards to flush out the semen

[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]

m070298 said:

Hey fellow nursing students. I am having little problem with my pediatric case study. Any ideas where I can find some help. She had surgery for dental cavities. I have gone through my care plan book that I have, and I believe I am about to go a little crazy. Lol. Help..

Oral care is a problem for most as many nurses don't get to have a patient that needs oral care. I happened to have had extensive oral surgeries and oral problems secondary to radiation therapy and happened to be in nursing school with a dental hygienist who wanted to change professions! Most all oral care is aimed at comfort such as relieving pain. Outside of that, treatment is usually aimed at healing whatever has gone wrong and preventing it from happening again. Without preventative care people lose their teeth. I've put together some links for you to check out. One of the links gives the events that occur that lead to tooth loss when left untreated. Do you know the extent of the damage of the tooth structures? Is there gingivitis present? If so, then, treatment needs to be started for that. You can find information on the treatment of gingivitis or tooth abscess by doing a search on the medline plus website. Knowing the pathophysiology of tooth decay is a good place to start. A child is going to be a good candidate for teaching of good oral care.

[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/

[cavery]

I have been using the same book with much success. Always ask yourself: What is the most important aspect of the disease? Usually pain comes before anything else.

Claudia

[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.

[discobunni]

This guy has so many problems, I don't know what to prioritize here... They all seem to go hand in hand somehow. Now the other students tell me to avoid cardiac patients for care plans, too late! I've spent hours already organizing the info, etc and am in a time crunch!

He was admitted for afib, but has severe bruising from falling

Forearm from elbow to wrist is bruised 85%. Rt inside leg by knee has redness and echymosis approx. 5" x 4". Left outside leg by knee has redness and echymosis approx. 7" x 9". There is no edema, drainage or approximation.

Coccyx - red blanching w/stage 2 blister 1" x 2", no edema, echymosis, drainage or approximation.

...generalized weakness. Hypertension 147/83 bilat. His i/o is 3000:3100, iv fluids running @ 125.

High levels of wbc from uti, but also high bun (35 on admit now 39) and creatinine: (1.3 on admit, now 1.6). Bc & electrolytes w/in normal range.

Hr is 117, irregular and weak pedal pulses. Hospital meds are: metoprolol, simvastatin, asprin, levofloxacin, digoxin, diltaziem. No o2 is running. Rr 18 & not deep or shallow. So I'm thinking circulation priority. I've narrowed it down to these nanda:

• Impaired skin integrity
• Decreased cardiac output
• Impaired mobility: generalized weakness
• Ineffective tissue perfusion: (would this apply to severe bruising?)
• Self-care deficit

Ugh, I'm really stuck on this one. They all seem to relate somehow to me. Any help to get me thinking in the right direction would surely help!

[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!

[Daytonite, BSN, RN]

foxdog said:

i am just starting lpn school. in desperate need of help writing care plan for dehydration. maybe a sample of one would help.

I will help you with your care plan. Let's do this on a step-by-step basis. first, of all... Is this a real patient? If so, have you done a physical assessment of this patient and reviewed the chart? If not, have you looked up the signs and symptoms of dehydration? If not, here is a page at family practice.com that lists that information including what the doctors will do to treat this.

Pediatric Dehydration.

Look at the what the presenting symptoms are weakness, visual changes, and leg cramps. I know about the visual changes because i was hospitalized with dehydration a couple of years ago and the visual changes i had were scary! The labs are also very telling. Elevated buns and electrolytes out of whack. You can also take a look at the pediatric dehydration profiles on this site for more information for signs and symptoms. Here are links to more information about dehydration:

Dehydration Causes

What Is Dehydration?

Do you have any care plan books to help you at all? Basically, the next steps are to group your signs and symptoms into nursing diagnoses and then create nursing interventions for each of the signs and symptoms your patient is having. I will help you with this if you will list those signs and symptoms for me.

[Daytonite, BSN, RN]

audy_lagz said:

39 ye31 yr old man visits his hc provider with complain a burning epigastric injury occuring 2 hours after he eats. he consistently feels bloated and obtains little or no relief from otc antacids. his last health history- cigarette smoking, stressful job, chronic use of nsaid and diagnosed peptic ulcer.

Here is information on peptic ulcer disease, etiology, symptoms, how it is diagnosed and managed medically.

Peptic Ulcer Disease

Your main problems are most likely going to be what i have listed below and bold-faced. Feel free to add other symptoms i might not have considered. I have not included any of the medical tests that might be ordered or the medications or treatments the doctor might order. I'll let you do that since it may be different from what is done here in the u.s. I didn't address anything related to helicobactor pylori testing or treatment which i'm sure would be undertaken. You'll want to address the side effects or special needs of the patient receiving medications and treatments, so don't forget to include those.

Mid-epigastric pain, deep recurring ache relieved with food or antacids and aggravated by general irritants (below)

• nocturnal pain is present and aggravated by food
• anorexia
• weight loss
• nausea or vomiting

In developing your care plan, what you are going to do is address each of these symptoms that are listed and have nursing interventions for each of them. Now, here in the u.s., we make a distinction between actions that a nurse can do independently from the doctor and those that depend on a doctor's order (we call those collaborative interventions). If you have a care plan book you can find these interventions listed under these symptoms very easily, or in a nursing textbook.

If you need further help, post another question to this thread.