Help with Careplan

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Hey all, so I am now on my second care plan. I did so well on my first thanks to the help here, that I figured I would come back for more. My patient went in into E.R. with abdominal pain, ended up having surgery that evening, it was ABdominal reconstruction surgery- Hernia repair. From his record folder i see where a blood transfusion was also given, although I don't understand why. Anyhow the surgery was successful. However once it was all said and done he was than experiencing dypsnea,shallow lung volume with severe pain when breathing deep, the patient also said "coughing is out of the question" because of the pain. They said it is decrease in pulmonary vascular congestion as well as bibasilar atelectasis. They also suggested it could be aspiration pneumonia, and his white blood counts are high, and they have listed as probable leukocytosis. 2 days ago he had a CT that showed a fairly large spot on his lung. I talked to his nurse and she said that the family is thinking its an embolism, howver she said it looks like the C-word. Anyhow so he is now on pain meds and bedrest I suppose until they understand what they are dealing with. He is on a pin level of 7-8, and there is drainage from the surgical wound. He is on albuterol sulfate, ancef, dilaudid, heparin Sodium, Phergan, Zofran. I have to come up with 8 nanda diagnosis for this patient. The on bad mark i did get on my last careplan is that i had too many at risk fors. So i need help coming up with 8. However I do believe it is okay for risk for infection to be a very high priority. I just need help coming up with them, and even more than that putting them in priority order which im not very good at. I know it goes ABC, however it isnt as easy as that..... so any suggestions for diagnosis would be much appreciated. Also his number one complaint now is nausea and pain. So i suspect I will mostly be keeping the patient comfortable, not sure what kind of goals I can set for him. Thanks a lot!!!

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

last week i gave you some information on how to put together a care plan. you should again review these threads:

if you have a book of nursing care plans or a book of nursing diagnoses you should read through the first chapter(s). they go through the nursing process and how this relates to writing a care plan, particularly the choosing of nursing diagnoses.

you cannot do anything until you make a list of all the abnormal data you have from your patient. it is that abnormal data that becomes the defining characteristics that will determine what nursing diagnoses you use. now, you already have some good information here. you just need to extract it out.

  • dyspnea
  • high white blood cell counts
  • pain
  • drainage from the surgical wound (what does it look like, how much, any odor)
  • nausea

there are 5 nursing diagnoses that you can get from those symptoms alone. i am curious as to why you didn't list the ones you already have. is this patient on ivs or is he eating yet. is he still npo? don't get too caught up in the medical diagnoses. keep your eye on what his symptoms are and what you are going to do with his symptoms. the doctors do their thing with the symptoms, we nurses do our thing with the symptoms.

to sequence your nursing diagnoses you can use maslow's hierarchy of needs. from top to bottom they are:

1. physiological needs

  1. oxygen (oxygen has to get to the brain first, the lungs are next in priority, then the heart, and finally the other tissues of the body--this is what everybody calls the abcs)
  2. food (this includes solid food, water, vitamins and minerals, or electrolytes)
  3. elimination (feces and urine)
  4. temperature control (fevers)
  5. sex
  6. movement (mobility problems)
  7. rest (sleep, inability to sleep or rest)
    comfort (pain, restless)

2. safety and security

safety from physiological and psychological harm

stability

3. love and belonging

4. self-esteem

5. self-actualization

need for learning, growth, health and autonomy

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