General Care Plan question

[jhzmize]

I am working on a care plan for a patient with many, many problems. This is a hemodialysis patient who just had a hand amputated due to dry gangrene, both legs had been previously amputated and a stent placed in his L circumflex due to a blockage. He has many obvious issues, but the problem that I am having is that many of these things did not show up in my assessment. I feel like I should be doing more than acute pain and risk for infection, but without the assessment data to back up the other problems, such as ineffective tissue perfusion, I'm not sure where else to go with it. Any suggestions?

[Lee J A]

Do you have any labs? I'm just a student myself but I would just go through the NANDA Dx list and see what applies. Seems easy until you have to do it....Goodluck!!

[jhzmize]

Most of his labs were normal with the exception of RBCs, Hgb, and Hct due to his dialysis. The problem that I am having is that his assessments were fairly normal and not a lot needed to be done for him with the exception of monitoring his vitals closely. My instructor stated that we should not use monitoring and assessing in our interventions as that is part of assessment, not truly intervention. Most of my time with him was spent either assessing or just talking because he seemed a little down.

[nurseprnRN, BSN, RN]

poor guy. how do you think you'd feel with both your legs and one hand off, and a risk for sudden cardiac death, after the miserable life you'd be living on chronic hemodialysis?

i just put this list as part of a reply to another student who didn't know how to start with her nursing plan of care. seems to me that you did (you picked up that he was "a little down," -- no kidding). you sat and talked to him for awhile when you could; that could well be seen as an intervention.

look in your nanda 2012-2014, which is the reference every student needs to learn about nursing diagnosis (available at your favorite online bookseller). flipping through the chapter indexes will give you some ideas; then you check out the list of defining characteristics and find the ones that make you say,"aha! that's it!"

take a look at these for possible choices. any of them ring a bell?

disturbed sleep pattern

hopelessness

risk for compromised human dignity

disturbed body image

disturbed personal identity /risk for disturbed personal identity

interrupted family processes

impaired social interaction

ineffective coping

fear

spiritual distress

risk for injury

delayed surgical recovery

acute pain

impaired comfort

social isolation

[jhzmize]

Thanks GrnTea. I used acute pain and risk for infection for 2 of my problems. I did go through the book to get some ideas for a direction to head in. Thank you for the ideas.