First semester student needs help with care plan--

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I need help with a Care Plan for a 64 y/o male, hospitalized yesterday for RLL Pneumonia and dehydration,

Past Medical history,Asthma , Chronic back pain, smoker 1ppd since age 16.Current medications, Rocephin, Advair,Albuterol,Percocet, Demerol, Acetaminophen. All labs are normal except for BUN at 34 mg/dl. I want to start with, Imparied Gas exchange, am I on the right track?

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Specializes in Nursing Education.

Given his dx (pneumonia) and his hx (smoker, asthma), then Impaired Gas Exchange and/or Ineffective Airway clearance are probably good guesses. What were the vital signs, especially his respiration rate and sats? Was his breathing labored? Did he have a cough? Get short of breath easily? These are the kinds of assessment data that can help you decide if that is a good nursing dx.

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Specializes in ICU, ER.
Given his dx (pneumonia) and his hx (smoker, asthma), then Impaired Gas Exchange and/or Ineffective Airway clearance are probably good guesses. What were the vital signs, especially his respiration rate and sats? Was his breathing labored? ...

This is exactly what I was going to ask. If his RR and/or SpO2 were abnormal and breathing was labored I'd probably go with Impaired Breathing Pattern. Were his ABGs out of whack? If so, I'd go with Impaired Gas Exchange...

Using a framework such as Maslow's Hierarchy of Needs or Gordon's Functional Health Patterns makes it easier to prioritize nsg dx.

Good luck!

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This is a senerio on a simulation man, they didn't give us his vitals. Labs and a short review of history. Thanks for the input, I am working on this with my team this week. I'll let you all know how we did.

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Specializes in Infusion, Med/Surg/Tele, Outpatient.

You have to go with what your evidence (assessment) shows you. You can't assume anything else is abnormal.

DX: RLL pneumonia, dehydration.

PMHx: Asthma, smoker, chronic pain.

Meds: Rocephin, Advair,Albuterol,Percocet, Demerol, Acetaminophen

Labs: BUN is elevated.

1. Know the 8 rights for these meds? Right Reason, Right Assessment

2. Dehydration/elevated BUN go together - ______ r/t ______ AEB dehydration, elevated BUN

3. noncompliance: asthma + smoker = very bad things

4. dx is pneumonia, but you have no other evidence for impaired gas exchange, ineffective breathing pattern, or ineffective airway clearance. What would be your AEB for these?

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Specializes in ICU, ER.

From http://www.virtualnurse.com/careplans/brainstorm.html:

Formulating a nursing care plan

A nursing care plan, or nursing diagnosis care plan, outlines the nursing care to be provided to a patient who suffers from an aligment. Learning to write a nursing care plan is difficult but there are a few key steps to remember when putting one together that will ease the process of writing a nursing care plan.

Characteristics of a quality nursing care plan

It focuses on actions which are designed to solve or minimize the existing problem.

It is a product of a deliberate systematic process.

It relates to the future.

It is based upon identifiable health and nursing problems.

Elements of the nursing care plan

NANDA nursing diagnosis with related factors and diagnostic criteria

Nursing outcome classifications with specified outcomes to be achieved including deadlines

Nursing intervention classifications with specified interventions.

This is the best book ever!

http://www.amazon.com/Nursing-Care-Plans-Guidelines-Individualizing/dp/080361294X/ref=sr_1_5?ie=UTF8&s=books&qid=1272858233&sr=1-5

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