Desperately Need Help With Care Plans

Nursing Students Student Assist Nursing Q/A

Any help with care plans will be appreciated?

Specializes in med/surg, telemetry, IV therapy, mgmt.
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I am new to the site and i cannot seem to find a place to post a question. I am doing a care plan on a pt that dehisced after have a lobe of the liver removed due to cancer. Hospital stay is 3 weeks. I am thinking that one a few of my nursing diagnosis' could be impaired mobility, infection and i have no idea of what to do for the third diagnosis. Any ideas would be greatly appreciated.

Nursing diagnoses, like medical diagnoses, must be based upon the signs and symptoms that the patient has to support them. Nursing diagnoses are about the patient's responses to their medical diseases and conditions, not re-diagnosing them with another medical condition. Infection is not an official nanda nursing diagnosis. Infection is a medical diagnosis and a medical decision and cannot be used as a nursing diagnosis. You need to break the signs and symptoms of the patient's infection down into its component symptoms and use them to come up with a nursing diagnosis. For example, if fever is one of the symptoms of the infection, then use the nursing diagnosis of hyperthermia.

If this patient has liver cancer and had surgery, they are a postoperative patient. They need to be monitored for side effects from general anesthesia. Those include:

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

And there are nursing diagnoses for some of those. A dehiscence is a break in the skin and tissues and is impaired tissue integrity. Does this patient need any post op teaching? What will they need to know about incision care upon discharge?

aLways make sure that your goaLs are S.M.A.R.T

S- Specific.. You don't want to place a hammer on your head because your goal is too broad. right?:wink2:

M- Measurable

A- Attainable.. Don't pressure yourself too much. you have to think that what you're dong is for the fast recovery of your patients. If you think you can't attain your goaLs, find alternatives.

R- Realistic.. Your dealing with real life here so make sure that in doing your interventions, make sure that your base is REALITY and not some comic strip you want to put to life.

T- Time-Framed.. whether your duty shift is 8 hrs. or 16 hrs., always keep in mind that time is very important in our lives as nursing students. So, what i aLways do is, after checking the patient's chart, I always make a time table of everything i will do in the 8 hrs. of duty. And i see to it that n making my care plans, my goals are time-framed to provide my patient maximum care as possible for the whole 8 hrs.

And Lastly, I read Nursing Care Plans books as my guide in making care plans.

I hope I helped you..

So.... I need 2 DX for my care plan and then I need to prioritize the rest and I'm not 100% sure.

I originally thought of using DELAYED SURGERY RECOVERY or IMPAIRED ORAL MUCOSA and NUTRITION LESS THAN BODY REQUIREMENTS. However, my nur dx book states not to use these and instead use KNOWLEDGE DEFICIT and RISK FOR INFECTION r/t surgery. I know my RISK DX are last and I think I have those in the correct order but Im not sure about the others. Also I have alot of different ones for KNOWLEDGE so I think they have to all be separate PES statements right? Also do I need a nur DX to address the stomach ache pt had b/c of NPO for the 1 day even though he said no pain? Its a little hard using Maslow's Hierarchy for this one so any input would be helpful thanks!!!

____________________________

PATIENT INFO:

16 y/o male, 10 day post op tonsillectomy vomiting blood and passed out. On admission no active bleed, LAB PT high. States no pain, just stomach ache from being on NPO all day. Vitals w/in range, breathing and moving without difficulties.

Resp: Hx Asthma, Hx smoking cigarettes 1/2 pack/day since 14 states quit 3 months ago, parent in house smokes. Toxicology screen: positive THC (marijuana)

Nutrition: 24 Hour diet recall Breakfast-milk & cereal, Dinner-Belgium waffle & ice cream (patient thinks scratched his throat and was the cause of the bleeding the following morning), states does not take daily vitamins and only eats 2 meals a day skipping lunch, says favorite food is cookie cupcakes, weight is within range.

Hygeine: Brushes only 1 x day, no mouthwash, rarely flosses

Low activity: hobbies/likes- listening to music (uses ear buds alot but doesnt clean them, video games and rare occasions plays handball, sits out most gym classes with asthma note.

Safety: cannabis on toxicology report, pt states 5 mos ago broke hand from fall when trying to jump a certain number of stairs and missed.

__________________________________________________ ____

1- KNOWLEDGE DEFICIT post op diet restrictions

2 -KNOWLEDGE DEFICIT effects of cigarette/canibas smoking w/ asthma

3-KNOWLEDGE DEFICIT effects of drug use

4-HEALTH MAINTENANCE INEFFECTIVE asthma management w/ smoking

5-HEALTH MAINTENANCE INEFFECTIVE poor eating habits & lack of vitamins (or do they need to be seperate?)

6-ACTIVITY INTOLERANCE r/t insufficient knowledge of adaptive techniques needed 2ndry to Asthma

7-SEDENTARY LIFESTYLE low activity

8-READINESS FOR ENHANCED COPING pt quit smoking

9-HEALTH MAINTENANCE INEFFECTIVE inadequate dental hygiene

RISKS are last:

10- Risk for Ineffective Resp Function r/t bleeding of throat

11- Risk for Bleeding r/t surgical incision

12- Risk for Infection r/t surgical incision

13- Electrolyte Imbalance r/t vomiting

14- Risk for Infection r/t excessive use of ear buds (fungal infection of outer ear)

Just keep in mind maslows hierarchy and your abc's ?

LVN2006 said:
any help?

Definately make sure your goal is measurable and positive. I used to get a lot of red ink for that one! I have this book: Nursing Care Plans by: F.A.Davis. It's grey. We get a lot of benefit from it, it even lists the "As Manifested By:" included and a great CD ROM too.

One thing I learned is instructors can see when you're taking NANDA's from books instead of being original. I've improved on my NCP's by making my interventions very individualized and incude S/S with specific goals. That made a big difference. Still no matter what, instructors may criticize, constructively of course....

Good luck to you!

I am just finishing RN school after being an LPN for 20 years. My job right now is in care plan writing, so it wasn't a very hard part of my nursing school. I did find that my favorite care plan book was "Nursing Diagnosis Handbook - A guide to planning care." by Ackley and Ladwig. I went and spent $40 on a care plan book, then got this one through Amazon - used for about $6. I got much more use out of this one.

Hope that helps.

Stephanie in FL said:
I've been an RN for 15 years and I also had difficulty with care plans. I would look at books and/or nursing journal articles for assistance. For emotional or cognitive nursing diagnoses, talk to your patient-many of your interventions will come from what he/she thinks will work. Good luck!

Stephanie RN

We have to do a list of nursing ques. I hated doing this 1st semester b/c it seemed ridiculous. I just turned it into a game/challenge. I try to get as many ques as I possibly can as I go thru my head to toe assessment. As I go thru each body system I them come up with some idea of the ndx. I tend to work it backwards ie starting w/ the ndx, then substantiating it w/ the ques. I found an excellent website. It is orthodox.net and it take you thru all the body systems and then at the end of each body system it ques you for a ndx. The subjective info that I garner in the into is also very helpful. This is what Stephanie in Fl is writing about. I always ask the pt. "Why are you here? They are always happy to elucidate and catch me up. Then I go to elsevier and/or Ackley's book and formulate a goal.

Specializes in Telemetry/Med Surg.

At our school, we can't reference the actual care plan books but can use them for guidance to setting up the plan and the interventions & outcomes. We actually have to use our assigned nursing texts and reference those pages. They must be specific to the patient's condition and your interventions. It sounds like a pain but I've learned so much this way. but like I mentioned, I do use a care plan book for guidance only. Good luck.

I am in nursing school to be an lpn I know how to write a careplan I'm just not sure how to write nursing interventions like how do I word them...

Iknow what I wanna do we are learning using pretend patients and my patient is a woman and has a uti i already wrote my diagnosis - acute pain rt bladder infection aeb pt. States "it hurts when I pee" and my goal -patient will state "it doesn't hurt when I pee" by 3/15/06 now I need to write 5 nursing interventions i want them to be something like.

Assess pain on scale of 1-10, drink cranberry juice, teach pt. How to wipe from front to back and how to lower chances by drinking plenty of water. I still need one more. But i'm just not sure how to word it. Can anybody help? Assignment is due by friday its wednesday if you have any input i'd really appreciate it!

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

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

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

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