Desperately needs help with my first care plan

Daytonite, BSN, RN · Feb 20, 2010

i see that you are a new poster on allnurses and that you already posted about this on the nursing student discussion forum. there is a thread that explains how to write care plans that you should be reviewing where the care planning process is gone over and there are many examples of how its done: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. the care planning process is done by the nursing process. why? because care planning is problem solving and the nursing process is the tool for problem solving that we use. if you follow the steps in sequence you will get to your final destination--solving the patient's problem(s).

first of all i want you to realize that diagnosing is done in many different disciplines. doctors, car mechanics, plumbers. diagnosis is just a fancy word for saying you are determining what the problem is. but all jobs that engage in fixing problems do pretty much the same process to get to finding the problem and solving it. the difference is that each one has a unique set of information that they have to deal with. we have to know about medical diseases and nursing care.

step 1 assessment - assessment consists of:

a health history (review of systems) - 80 year old female with atrial fibrillation and chronic pulmonary embolism. she has a history of falling a month ago because of being weak and dizzy and sustaining a concussion.
performing a physical exam - the only physical exam information provided is that she is weak, dizzy and confused. no heart sounds, lung sounds provided.
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - no information provided
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - each medical condition should be looked up and textbook symptoms compared with the patient's symptoms to see if you missed seeing any them. also the pathophysiology of the conditions is needed to help you determine the etiology ("related to") parts of your nursing diagnostic statements
- http://www.merck.com/mmpe/sec07/ch075/ch075e.html - atrial fibrillation
- http://www.merck.com/mmpe/sec05/ch050/ch050a.html - pulmonary embolism
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - none provided. these can give you clues as to other conditions that the patient has as well as to potential problems that side effects of the medications might be causing.

step #2 determination of the patient's problem(s)/nursing diagnosis - this is where you need to sort through the assessment data and separate out what is normal and abnormal. abnormal data is the evidence of problems. the only real evidence that you have provided is that the patient is weak, dizzy and confused and i am sorry to tell you that these are not symptoms (according to nanda) of decreased cardiac output. symptoms of atrial fib are dyspnea, dizziness, palpitations. someone with pulmonary embolism will generally have tachycardia along with weak and rapid pulses and hypotension (this is evidence of decreased cardiac output), low grade fevers, and possible a productive cough that may be blood tinged (ineffective airway clearance). however, your assessment information doesn't report any of that. weakness is evidence of something like fatigue, confusion is evidence of acute or chronic confusion and dizziness would be concern for risk for injury which are all nursing diagnoses. this patient also warrants a diagnosis of risk for falls because of her prior history of falling and her age.

step #3 planning (write measurable goals/outcomes and nursing interventions) - this part of the care plan is based on the abnormal assessment data that you obtained. just as a doctor treats the symptoms of a disease we nurses also treat the symptoms of a nursing problem. if a patient has acute confusion and the symptoms are they hallucinate or do not know place or time, your nursing interventions are to do something about those. your goals are what you anticipate will occur as a result of your nursing interventions being performed.

you need to review your assessment data because it is not complete.

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decreased cardiac output r/t a-fib amb dizziness, weakness and confusion.

the related factor of a nursing diagnostic statement cannot be a medical diagnosis. it must be the cause of the decreased cardiac output in more generic terminology. this is why you must know the pathophysiology of atrial fib and what actually causes it. the related factor is what is causing the nursing problem. a nursing diagnosis reference will give you suggestions for related factors for this diagnosis, but they are very broad based.
as i said above weakness and confusion are not manifestations (symptoms) of decreased cardiac output. dizziness may be if you get the correct related factor for this diagnosis.

nicolep13 · Feb 20, 2010

Hey- Thanks for the input.. The thing is, our instructor gave let us look at the pt. chart and get as much info as we could- I haven't had a chance to actually assess her. She wants us to make a care plan from a diagnosis that she gave us. Mine happend to be A-Fib. I know very little about her- I know she is an assist X2 with all transfers, and I know that she is on cumadin. 3.5 mg M,W,F and 3 mg. Sun, Tu, Th, Sat. Her chart was very unorganized with info all over the place, the fact that I have never read a pt chart before didn't help, but I only had about a half an hour to get as much info as I could. My instructor did say though that the r/t could be a medical dx. But now I am back to square one with the dx. Crap!!!! It is hard to do this without really knowing anything about the pt.

Thanks for your help though :)

Nicole