Desperately Need Help With Care Plans

Any help with care plans will be appreciated?

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Can be downloaded from https://carescribble.com/

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

Hi, negrita!

The care plan process always starts with the data that you have collected (Step #1 of the nursing process). From that data you make a list of the abnormal, or the things you discovered that are not normal. These things become the symptoms, or patient's defining characteristics (NANDA language), that will help you to determine that Impaired Skin Integrity is the correct nursing diagnosis to be using (Step #2 of the nursing process).

Please list these abnormal symptoms for me, so I can help you with this.

Welcome to allnurses! :welcome:

Specializes in med/surg, telemetry, IV therapy, mgmt.
negrita said:
Ct had a femoral/poplital bypass. client past helath history is HTN And DVT.

I don't think you are understanding me. What you have responded with are medical diagnoses. This is of no help. A care plan addresses the problems your patient has. These problems are based upon abnormal assessment data, not medical diagnoses. For example, since the patient had a femoral/popliteal bypass I would assume that there is an incision. Are there any problems with the incision? Does the patient currently have any open skin ulcers on the affected lower limb? If so, what is the description of them? Is there any pedal or lower leg edema? Any changes in sensation? Did you assess the patient's ability to perform ADLs? Can the patient walk? The answers to these questions are potential abnormal assessment data that need to be known in order to design and work nursing interventions into a care plan. While Impaired Skin Integrity is one possible diagnosis there is a possibility based on the little bit of medical diagnosis information you have supplied that the patient might also have Ineffective Tissue Perfusion, peripheral and Decreased Cardiac Output. However, I can't verify that without knowing your assessment data. Is this a real patient or a non-existent subject of a case study assigned by your instructor?

i would like to but we were just given this situation :

patient name (age, religion, location) was admitted at the hospital due to multiple fracture and lacerations after an mva. 1 hr pta, pt was with her bf driving along the highway at 150 kph when suddenly, her bf lost control of the motorbike.

patient was thrown 15 m away. residents near the accident site brought them to the er. her bf was pronounced doa while patient was rushed to or. upon initial visit to patient, you observed that both legs have casts. multiple lacerations and contussions are observed on her fae and all over her body. patient doesnt want to eat or talk to anyone. she wasnt able to take anything by mouth since her operation. V/S revealed

t - 38.6

p - 95 bpm

r - 19 cpm

bp - 130/90

for certain, the patient has the following probs - she cant move, she won't eat (im uncertain as to whether how long it has been between her operation and the 'today' of the situation and whether she has an IV or not and whether this would be enough for the moment to sustain her nutritional needs) and she has a fever.

given that situation, we are supposed to come up with a care plan and a discharge plan. :(

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

In your original post you asked for help with the nursing diagnoses and which ones should be listed (focused upon) first.

This patient has sustained a major trauma, has had surgery and suffered a major personal loss with the death of her boyfriend. The first step in writing a care plan is to assess your patient. Assessment data has been given to you in the information provided. From the scenario, i have isolated the following abnormal data (problems):

  • multiple fractures
  • multiple lacerations
  • multiple contusions on her face and body
  • both legs have casts
  • patient doesn't want to talk to anyone (assume this is an indication of her grief over the death of her boyfriend)
  • wasn't able to take anything by mouth since her operation (this could be due to nausea from the anesthesia, an unknown injury in the accident you weren't told about, or grief over the loss of her boyfriend)
  • temperature of 38.6 degrees (elevated)
  • pulse 95
  • b/p 130/90 (slightly elevated)
  • pain [i've added this because it's reasonable to anticipate that the patient will have pain because of her injuries]

In step 2 of the care plan process you need to match these problems, or symptoms, with defining characteristics of nursing diagnoses that will apply to this patient. To do that you need your nanda nursing diagnosis reference book to confirm that you are matching these items to the correct nursing diagnoses. These are nursing diagnoses that will fit with these symptoms in the sequence of importance:

  • imbalanced nutrition: less than body requirement r/t lack of interest in food aeb wasn't able to take anything by mouth since her operation
  • impaired tissue integrity r/t traumatic injuries aeb multiple lacerations and multiple contusions on her face and body
  • hyperthermia r/t trauma aeb temperature of 38.6 degrees
  • impaired physical mobility r/t immobilization of legs aeb multiple fractures of bones with casts on both legs
  • acute pain r/t traumatic injuries aeb elevated blood pressure and heart rate [patient would also be reporting she was having pain]
  • grieving r/t death of boyfriend aeb patient doesn't want to talk to anyone
  • risk for infection r/t traumatic tissue injuries
  • risk for injury r/t immobility [thinking of the potential to develop a dvt here]

Now, that all the problems (defining characteristics) have been divided up and placed with nursing diagnoses, the next step is to develop goals and nursing interventions for them. So, you need to look in your nursing textbooks to find nursing care for:

  • ways to encourage the patient to eat
  • lacerations and contusions
  • care of a patient with a fever
  • an extremity with a cast, care of the cast
  • interventions for the patient having pain
  • how to help the patient deal with her grieving at the loss of her boyfriend and the emotional burden she has at this time
  • actions you will need to take to avoid the patient developing an infection of any of her wounds
  • actions you will need to take to help prevent the development of a dvt in her legs that have casts on them

Since this patient also underwent surgery a few other potential problems should be observed for and prevented:

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • urinary retention
  • constipation
  • nausea/vomiting (due to paralytic ileus)

If you like, you can work them into the nursing diagnoses as other "risk for" diagnoses.

Specializes in med/surg, telemetry, IV therapy, mgmt.
Quote
Can someone help me to create nursing diagnoses for asthmatic patients?

The first step in choosing a nursing diagnosis involves assessing the patient. Any nursing diagnosis is always based upon the signs and symptoms the patient is having. These signs and symptoms are abnormal assessment items. Depending on how thorough your assessment of the patient is will determine how well your care plan is going to attend to the patient's problems.

With asthma, the patient is, in general, going to have these symptoms in order as an asthma attack worsens:

  • hacking, non-productive cough (due to bronchial edema)
  • restlessness
  • diaphoresis
  • only able to speak in short, broken phrases
  • eventually the cough become productive of frothy, clear sputum
  • breathlessness
  • chest tightness
  • dyspnea (shortness of breath)
  • use of accessory respiratory muscles
  • hyperresonance
  • tachycardia
  • some mild systolic hypertension
  • inspiratory and expiratory wheezes
  • crackles (as spasm and obstruction worsen)
  • prolonged expiratory phase of respiration (due to bronchospasm)
  • mucusal edema
  • mucus plugging with mucus trapped behind airways that are narrowed or occluded
  • diminished breath sounds
  • cyanosis, lethargy, confusion and hypoxemia (as the patient proceeds to status asthmaticus or respiratory failure)

Based upon one or more of these above symptoms being present, nursing diagnoses that would be appropriate to use, in priority order, would be:

  • gas exchange (abnormal skin color, confusion, cyanosis, diaphoresis, shortness of breath, hypoxemia, tachycardia, abnormal blood gases) - this diagnosis is generally used when there is hypoxia, hypoxemia or the patient is getting close to it
  • ineffective breathing pattern (alterations in the depth of breathing, shortness of breath, orthopnea, prolonged expiratory phase of expiration, use of accessory respiratory muscles to breathe) - the act of breathing is not providing enough air
  • ineffective airway clearance (any kind of cough, ineffective cough, any kind of adventitious breath sounds, any kind of changes in the rate or rhythm of the respirations, difficulty speaking due to breathing impaired, excessive sputum production) - this diagnosis is when the person is having difficulty clearing secretions from the respiratory passages in order to maintain a clear airway
  • fear (fear of suffocation or death) - threats to the self that the patient recognizes as dangerous
  • anxiety (obsessive tinkering with oxygen equipment, over attention to medication, treatment, physical symptoms) - warnings of impending danger causing patient to take measures to deal with threats

Examples of a nursing diagnostic statements using the above nursing diagnoses for an asthmatic patient might be:

  • impaired gas exchange related to alveolar-capillary membrane changes as evidenced by cyanosis, lethargy, confusion and hypoxemia
  • ineffective breathing pattern related to fatigue as evidenced by prolonged expiratory phase of respiration, shortness of breath and the use of accessory respiratory muscles to breathe.
  • ineffective airway clearance related to airway spasm as evidenced by diminished breath sounds with inspiratory and expiratory wheezes and shortness of breath.
  • fear related to threat of suffocation as evidenced by increased excitement and statements of "i'm not getting enough air!"
  • anxiety related to fear of suffocation as evidence by patient constantly checking to make sure oxygen tubing is correctly positioned and asking what the setting of the oxygen flow is.

It would be very useful to have a book of nursing diagnoses or care plans that include the nanda definitions, defining characteristics and related factors since nanda is very specific about how each of the nursing diagnoses should be used.

anyone there who could help me to make a Nursing Care Plan about lady partsl bleeding and threatened abortion. i dont have any books about Care Plans.

pls help me. i dont have any reference thats why i dont know how to make a care plan. pls help me. my deadline is tomorrow

Can anyone help me with 2 nursing diagnosis relating to pneumonia? I choose activity intolerance and infection.

Specializes in med/surg, telemetry, IV therapy, mgmt.
angie123 said:
Can anyone help me with 2 nursing diagnosis relating to pneumonia? I choose activity intolerance and infection.

Please read some of the posts in this thread. the only way you can "choose" any nursing diagnoses is if your patient with pneumonia has the symptoms that match with those nursing diagnoses.

The symptoms (defining characteristics) of activity intolerance are:

  • abnormal blood pressure response to activity
  • a abnormal heart rate response to activity
  • electrocardiographic changes reflecting arrhythmias
  • electrocardiographic changes reflecting ischemia
  • exertional discomfort
  • exertional dyspnea
  • verbal report by the patient of fatigue
  • verbal report by the patient of weakness

The definition of this diagnosis is "Insufficient physiological or psychological energy to endure required or desired daily activities". All of this above information comes directly from page 3 of nanda-I nursing diagnoses: definitions & classification 2007-2008 published by nanda international. Your patient should primarily be having shortness of breath upon physical activity and possibly arrhythmias and evidence of cardiac ischemia (chest pain, cyanosis, irregular heart rates). If this is not the case, then you shouldn't use this nursing diagnosis. If your patient has dyspnea on exertion, your nursing diagnostic statement would be written like this: activity intolerance (nursing diagnosis) related to exertional dyspnea (related factor) secondary to pneumonia as evidenced by shortness of breath upon ambulating 10 steps to the bathroom (patient symptom; abnormal assessment data item).

There is no official nanda nursing diagnosis of infection. Infection is a medical decision and medical diagnosis. You can, however, use nursing diagnoses for the manifested symptoms that the patient has of the infection, such as fever, leukocytosis (elevated white blood cell count), redness at a localized site of infection along with heat, pain, edema and sometimes loss of function due to the pain and swelling. (review the inflammatory response in a reference book on pathophysiology.) these symptoms you can develop nursing diagnoses for and, subsequently, nursing interventions.

I think those interventions are great! You are going to make one heck of a teaching guide for the new mommies!

I'm attaching some of my teaching care plans for when I went through ob. I hope you can get some ideas from them.

mother discharge instructions worksheet.doc

infant discharge instructions worksheet.doc

Scenario: Female (36), fever, shortness of breath on occasion with frequent and productive cough. Wheezes in both LL.She has been sick for 3 weeks, cries easily and several bruises on both forearms

Diagnosis:

1. Elevated body temp r/t illness emb vital sign

2. Ineffective breathing r/t airway obstruction emb productive cough and lung sounds

3. Anxiety r/t illness emb pt's crying.

The question is what about bruises, I think it from previous treatment?

How do I state it?

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