Desperately Need Help With Care Plans

Any help with care plans will be appreciated?

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

Listing the abnormal findings in the data you presented in your post you have the following:

  • patient's statement of a lump on her urethra
  • failure to seek medical help
  • financial problems
  • worry over time away from work
  • fatigue related to enlargement of the lump

I would group these into any one of the following nursing diagnoses:

  • Decisional Conflict R/T support system deficit and perceived threat to value system AEB failure to seek medical help because of financial problems, worry over time away from work and fatigue.
  • Ineffective Health Maintenance R/T lack of material resources AEB failure to seek medical help due to statements of financial problems
  • Deficient Knowledge R/T misinterpretation of information AEB belief that fatigue results in the enlargement of the lump on her urethra.

Just out of curiosity, did you do a review of systems with this patient about her genitourinary system? Is she having any pain, discharge or trouble with urinating?

Specializes in med/surg, telemetry, IV therapy, mgmt.
alexan18 said:
Need help with care plan for mrsa..

Any help would be appreciated...

MRSA is methicillin-resistant staphylococcus aureus. Can't give you any specific help without knowing what you need. Is this a real patient or a case study? Did you do an assessment of the patient? Is the infection in a wound or an organ system? Do you have a listing of the non-normal symptoms you developed from your assessment? What working nursing diagnoses have you come up with so far?

When doing nursing care plans you have to get away from thinking so much about the medical diagnosis. It's ok to use the same symptoms that also determine the medical diagnosis. Symptoms are not for the sole property and use of the physician. However, nurses are going to turn those symptoms into nursing diagnoses. Your care plan is going to ultimately end up having nursing interventions that address these symptoms the patient has--not the medical diagnosis per se. We will have some collaborative responsibility in reporting progressive or developing symptoms of a medical condition.

Here are links to information about MRSA:

Staphylococcal Infections - Medscape

Methicillin-resistant Staphylococcus aureus (MRSA) - CDC

Staphylococcal Infections - MedlinePlus

I was wondering if someone can tell me a better explanation of the nursing process. I get that the process has 5 steps and they are Assement, Nursing Diagnosis, Planning, Implentation, and Evaluation. But i need to know how to use them in critical thinking.

And

I am really lost in the nursing diagnosis. I cant tell the difference between nursing diagnosis and medical diagnosis. Any ideas for me to get this

Specializes in Tele, ICU, ER.

Ok I'll see if I can help a little, remembering from when I learned it...

You use the nursing process all the time for problem solving, just worded differently for real life...

Using ADPIE, you might say...:

Assessment: Closet full of clothes that haven't fit you in years

Diagnosis: Lack of wardrobe appropriate to office X-mas party, related to losing 30 pounds, as evidenced by a closet full of clothes size 18.

Plan: Buy a decent dress that shows off your new figure, for the party

Implementation: Dash over to Ross Dress for Less, on the way home from work.

Evaluation: DAMN but that dress looked good and everyone commented on how much weight you lost!

The basic problem solving layout is something we all do, generally without even realizing it, so it's not as new as you think it is ;)

Now, to bring it to the hospital.. a Medical Diagnosis simple says, "This is wrong with the patient". A doctor's plan, so to speak, would resolve around how to cure or get rid of THAT problem. So when the patient is lying in the hospital bed, the docs job revolves around how to fix that problem, what drugs might work, what procedures, etc. The nurse, on the other hand, says to him/herself... "ok this guy is lying in bed after abdominal surgery to fix a crapped out bowel. He's got the right meds, etc, from the doc." Yay good so far right? Now the nurse thinks..."This guy is 300 lbs, he likes to lie flat in bed to sleep, he's afraid his new incision is gonna open, he won't look at his stoma, he doesn't want to get out of bed cause his belly hurts and his family is eating McDonalds in front of him!"

Soooo... as a nurse you're gonna say, sit him up semi-fowlers, teach him to splint with a pillow to cough and deep breathe, work with him to learn out his stoma works and how to care for it as he's ready, encourage him to move and get out of bed as appropriate and explain to his family that if he really loves McDonald's but can't have it, maybe they should eat in the cafeteria.

The doc can fix the problem, but that problem (and its treatment) do lots of things to the patient that aren't the medical problem themselves, but are pretty major for the patient and his recovery. To choose an easy one from the above bowel guy...

Assessment: Pt. family eating McDonald's in the room is driving pt. nuts!

Diagnosis: Knowledge Deficit (family), related to lack of knowledge of patient's diet limitations as evidenced by pt. complaining that he wants McDonald's.

Plan: family will avoid eating in patient's room while his diet is restricted

Implementation: Teach family about diet restrictions, and how the smell of their food can cause the patient to have cravings that can't be satisfied right now.

Evaluation: Family has their meals in the cafeteria and encourages patient in his recovery so he can eat favoriate foods when appropriate.

These things are all hard to put into writing and words, because you learn to think like this automatically - that's why NANDA has a list, so you can use it to put your thinking-process into words . It comes with time, that is why you practice in nursing school.

Good luck, hope this helped!

:nurse:

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

Critical thinking is very simply making judgments based on facts rather than making random guesses based on nothing. Some of the steps in the nursing process provide you with the facts you need to continue onward to make judgments in the later steps. Critical thinking is nothing more than reasoned, logical thinking where each step of the process has rationale supporting it.

As you work through the steps of the nursing process for just one nursing diagnosis ask yourself these questions: what did i find in the patient's chart about him that wasn't normal? What did i find during my assessment that wasn't normal? What are those abnormal things telling me? If i put all those abnormal things together, do some of them look like they might belong together or be related in some way? What's causing them? When i look at this particular nursing diagnosis i see some of my patient's symptoms listed with it? Is this one of my patient's nursing diagnoses? I see that one of the related factors (cause) for this nursing diagnosis is something my patient has as well. That makes sense that this is the cause of these abnormal symptoms that the patient has. This sounds like it might be the correct nursing diagnosis because my patient has some of the symptoms that are listed with this diagnosis. Now, what about goals? Well, i want to see his symptoms get better, right? So, my goals are going to focus on how his symptoms are going to get better or go away. To do that, i'll need to choose nursing interventions to help that happen. Let's see, the first symptoms is ____. What, as a nurse, can i do for that? If i do this intervention, is that going to make the problem better or worse?

That is critical thinking. Taking facts you have and making some judgment and decision in working with them. That is how you use critical thinking skills to use the nursing process. Now, i know i may have exaggerated a bit, but i was trying to demonstrate to you the kind of thinking process that should be going on in your mind. When you've been a nurse for a while this critical thinking process of the nursing process happens so fast, that you'll miss it if you don't think about it. It will go painfully slow for you at first because doing this is all new to you. What you do is just follow the steps and keep asking yourself those questions as you go through each and every symptom every one of your patients has. Over your career you will do this thousands of times. The care plan is nothing more than the written documentation and evidence of your critical thinking.

Does that help you out?

I think that for now, just know that a nursing diagnosis is exactly what nanda defines each one to be. They are each defined by symptoms--the same symptoms that doctors use to formulate their medical diagnoses. A symptom is an objective observation or a subjective perception of the patient--facts. The doctors do not have exclusive use of symptoms, or facts. We nurses can use them too. With a care plan you are addressing problems, or symptoms, that a patient has. What nanda has done is grouped many of those problems, or symptoms, into what they are saying are related groups and put a label on them. They call the label a nursing diagnosis. The label that the doctors put on groups of symptoms are called medical diagnoses. We nurses have exclusive use of the nursing diagnoses. Use of medical diagnoses in our written care plans are forbidden territory to us. Got it?

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

Outcomes are the predicted results of our independent nursing actions. Independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. An expected outcome is measurable, patient centered, and specific. When you identify an outcome, you accept responsibility and accountability for helping the patient achieve that outcome.

Goals are the predicted results of collaborative nursing actions. Collaborative nursing actions are those things nurses can only do for patients with an order of a physician or another healthcare provider--things like administer medications or provide certain treatments, etc. Goals may also be measurable, patient centered and specific. What differentiates a goal from an outcome is that the nurse cannot take full responsibility and accountability for helping the patient to achieve a goal. Goals are achieved because of the collaborative management of many.

The major ideas you will see in the formulation of outcome and goal statements are the following:

  • improvement of the patient's condition
  • stabilization of the patient's condition
  • support for the deterioration of the patient's condition

While we would all like patient's to improve and get well, the facts are that some will not. It is perfectly legitimate to have outcomes that assist the patient in the deterioration of their physical conditions.

Our professor's asking us to do 10 NCPs on pregnancy complications, complete with rationales. She gave us a few nursing diagnoses:

Ectopic Pregnancy

1. Anticipatory grief r/t impending loss of pregnancy

2. Anxiety r/t pregnancy status

3. Knowledge Deficit r/t surgical procedure

Incompetent Cervix

1. Altered Comfort: Pain r/t early dilatation of cervix

2. Fear r/t possible pregnancy loss

3. Situational low self-esteem r/t inability to complete pregnancy

Hyperemesis Gravidarum

1. Altered Nutrition: Less than Body Requirements r/t nausea & vomiting

2. Deficient fluid volume r/t excessive emesis

Pregnancy-induced Hypertension

1. Altered urinary elimination r/t oliguria and anuria

2. Risk for injury r/t seizures

Placenta Accreta

1. Impaired gas exchange (fetal) r/t interruption of blood flow from placenta

I added a few of mine also. Are these statements okay? Ambiguous or not stated correctly? I would appreciate it if you help me with this assignment. If you know any websites that give rationales, pls mention it too. Thanks.

an6el1022 said:
How do you write a secondary to....I'm not clear on that and my instructor wants us to include that with all our actual dx's.

For example...for a pt that has cholelithiasis and biliary colic. I chose this

Acute pain r/t obstruction of bile flow 2° biliary colic AEB complaint of RUQ pain, crying, guarding

but I think I shouldn't have used the secondary to biliary colic since that is a medical dx??? What would have been a secondary to...Here is another one I used...

Imbalanced Nutrition: Less than body requirements r/t n/v 2° impaired bile flow AEB abd pain, inability to ingest food, inadequate calorie intake

How would I use the secondary to and someone please tell me if I did it correctly. Would a secondary be just another etiology??

We were taught in school that the secondary to part could be a medical dx because nursing is the treatment of the response to the illness, so your diagnosis is based on the person's response, and the response is secondary to the illness.

Does that make sense?

Specializes in med/surg, telemetry, IV therapy, mgmt.
trilli18 said:
Can someone please help me,

I am working on my care plan which is on a pt who's main diagnosis was COPD and other Dx this client had are: CHF, COPD, HTN, depression, anxiety, Afib, hyperlipidemia, CAD, MI, osteoarthritis, osteoporosis, and did smoke for 40yrs. Im working on the Diagnostic Tests sheet of my care plan - Labs on this pt. Sodium 142, Potassium 4.5, BUN 23, creatinine 1.0 and wbc 7.8, glu 151 and H/H -10.6/31.0 oh and some other info is pt on 3LNC continous --- pulse oximetery on 3L = 98% on RA =86%, on a regular NAS diet and rales heard in left lower lobe of lung. So with all this now the part im having trouble with is the interpretation of significance to my pt. Can anyone help me out please --- going insane.

Is this a real patient? What is the other assessment data or is the labwork all the data you were given?

Daytonite said:
Is this a real patient? What is the other assessment data or is the labwork all the data you were given?

Yes real pt. and that is all I was given

I have a real pt that has advanced pancreatic cancer with mets to liver. His prognosis is 3-5 months. He is jaundiced, and has a poor appetite and has had recent weight loss 91% of body weight. He is on morphine 15 mg po 12h which is keeping his pn down. He states 0 of 0-10. He is fully ambulating and needs no help with ADLs. He is on palliative care and is DNR. He has friends and family come visit. Other than this cancer which was diagnosed 3 weeks ago, he is in excellent health even though he smokes 2 packs a day. This is my first pt and first care plan. I need three nursing dx. I have come up with #1- chronic pain, #2 nutrition imbalance, less than body requirements, #3 risk for ineffective coping. The problem that I am having is for dx #1- his pain is currently being managed well though they did a comfort assessment and starting giving the morphine more often. What would be my related to? I know it is secondary to pancreatic cancer but I don't know how to put that in R/T terms. Also how do I do a SOAPE note on this? Like I said before this is my very first care plan and I do not feel as if I was given enough instruction on how to do this. Because the pt is on palliative care and DNR, how do I come up with interventions and evaluations and goals.

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

Collect All Your Data.

You need to make a list of the symptoms for all the medical diagnoses that were given for this patient, and there were quite a few!

Copd (scant sputum production with emphysema, excessive sputum production with chronic bronchitis, exertional dyspnea, chronic productive cough with chronic bronchitis, hypoxia with emphysema and cyanosis with chronic bronchitis, tachypnea, prolonged expiration, hyperresonant chest, diminished breath sounds, coorifice rhonchi and wheezes in bronchitis, s3 gallop, edema)

CHF (decreased left ventricular ejection fraction, decreased contractility, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, unexplained confusion or lethargy, fatigue, lower extremity edema due to venous insufficiency and lymphedema, hepatic engorgement and/or ascites, s3 gallop, jugular vein distension, pulsatile liver, rales, pulsus alternans and tachycardia, poor capillary refill, cool distal extremities, altered mental status)

HTN (b/p over 140/90)

Depression (sleep disturbance, appetite or weight change, attention or concentration problem, fatigue, reduction in pleasure or interest, feelings of guilt, suicidal thoughts)

Anxiety (nervousness, irritability, dread, insomnia, exaggerated startle response, easily distracted, unable to concentrate, muscle twitching, tremors, restlessness, shakiness, fatigue, muscle aches or tension, paresthesias, palpitations or tachycardia, shortness of breath, dyspnea on exertion, chest pain, sweating or cold palms diaphoresis, choking sensation, dysphagia, heartburn, nausea or vomiting, abdominal pain, anorexia, frequent urination, dizziness, lightheadedness, faintness, headache)

Atrial fib (dyspnea, dizziness, palpitations, exacerbation of congestive heart failure)

Hyperlipidemia

CAD (angina, nausea and vomiting, cool extremities and pallor, diaphoresis from sympathetic stimulation , fatigue, dyspnea)

MI (aka acute coronary syndrome) (chest pain similar to angina, pain often worse with activity and better with rest, pain radiates to arm, shoulder, hand, upper back, neck, jaw or throat; nausea, sweating, apprehension; pallor; tachycardia; s3 and/or s4 gallop; rales; jugular vein distension)

Osteoarthritis (deep aching joint pain, stiffness in the morning, crepitus in the joints, altered gait, contractures, decreased range of motion, joint enlargement)

Osteoporosis (usually asymptomatic until a fracture occurs in the vertebrae, distal radius or femoral neck, progressive deformity, kyphosis, loss of height, decreased exercise tolerance, low back pain, neck pain, elevated creatinine, history of tobacco abuse

Your scenario gave you the following abnormal data:

  • hyperglycemia (elevated glucose of 151)
  • low h&h
  • rales in the lll
  • pulse ox of 86% on room air

Let me backtrack a minute and say that all of the labwork is normal except for the glucose which is elevated, the h&h which is low and the bun which is only very slightly elevated and could be normal for an elderly man. Glucose will be elevated in diabetes, of course. But, it will also be elevated in acute stress, cushing's syndrome, pheochromocytoma, chronic renal failure, glucagonoma, acute pancreatitis, as a result of diuretic therapy and corticosteroid therapy and in acromegaly. I'm opting for corticosteroid therapy in this patient since he has copd and it's very common to give steroids to people with chronic lung disease. The low h&h indicates this person is losing blood. Probably slowly. Probably through the gi track. However, you don't have any other information to go on. So, it remains a mystery. I would care plan it as a potential problem and monitor for signs and symptoms of gi bleeding. Just fyi, the atrial fib, hypertension and tobacco abuse contribute to the chf.

Group Together Abnormal Data into Nursing Diagnoses.

That's going to be a big job because this patient has gobs of problems and a whole big list of symptoms! There are so many abnormal symptoms here that 5 different nurses could come up with a set of 5 different nursing diagnoses and each would be right. So, I'm going to give you my short list. This is your assignment, however. You know what the instructions are, I don't. Feel free to go your own way.

The first thing I see sticking out like a sore thumb is respiratory problems--big time. Including your lab data, this is what I come up with in priority order (by maslow's hierarchy of needs):

  • Impaired gas exchange r/t alveolar-capillary membrane changes aeb tachycardia, irritability, hypoxia, dyspnea, pulse ox of 86% on room air, skin pallor, hypoxemia, headache, and diaphoresis)
  • Ineffective airway clearance r/t chronic obstructive pulmonary disease aeb dyspnea, orthopnea, rales, rhonchi, wheezes, sputum production, and cyanosis
  • Decreased cardiac output r/t altered contractility and heart arrhythmia aeb rales, paroxysmal nocturnal dyspnea, decreased ejection fraction, s3 and s4 heart sounds, tachycardia, palpitations, jugular vein distention, fatigue, edema, prolonged capillary refill, elevated blood pressure, and atrial fibrillation
  • Impaired physical mobility r/t pain and physical deformity aeb limited range of motion and changes in gait
  • Fatigue r/t anxiety, depression and disease aeb lethargy, inability to concentrate, and sleep disturbances
  • Risk for deficient fluid volume r/t occult blood loss [that means blood loss whose reason is not known]

Planning

Independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. Your nursing interventions will actually be based on the items you have after the "aebs" of each of your nursing diagnoses. If you have a nursing diagnosis book it will be very helpful with choosing interventions.

The first site actually has a lot more nursing diagnoses than are listed, so if there isn't one on the list that you need, pm me and I'll check my list and let you know if what you are looking for exists on the gulanick site.

Implementation & Evaluation.

I don't know how far you are into doing that part of the nursing process for this assignment. Most of the time people have the worst time getting through the first 3 steps so step 4 and 5 are usually a breeze.

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