care plan

roser13, ASN, RN · Oct 15, 2011

What are your thoughts?

demylenated, BSN, RN · Oct 15, 2011

What level are you in?? Asking for help is great, and most here are willing to help, but my help is to suggest you invest in a good care plan book. It will answer all your questions... It seems you are wanting all the answers told to you - you won't get thru nursing school like that!!

There are some FABULOUS nursing dx books out there... you look up "anger," "Fx ribs," or "detox" and it will list dx and interventions with rationals...

Beyond that, what are you actual concerns? Your questions are broad, but also answerable by looking in a med/surge book or care plan book...

What are the possible consequesnces of his foot? What happens if you don't do anything? Answer those 2 questions and you have the answer to yours.

Why do you think he is being short? Possibly scared at the prospect of being paralyzed? In the hosp? Angry he was in a wreck? Angry he was caught DWU? Angry he faces jail time? So - fear and anger?

demylenated, BSN, RN · Oct 15, 2011

Also, use your ABC's and Maslow's to figure out the priority of care and nursing dxs that you need to consider.

simo96 · Oct 15, 2011

im 1st year, 1st semester. i dont want the answers told to me, and i have my diagnosis book in front of me, but im trying to figure out if acute confusion r/t alcohol abuse is a good diagnosis for this patient. or if it's because of a head injury......that's where im confused. also, with his foot, i know he can't really ambulate, so is prom going to even help him or is his foot too far gone??? maybe i worded my question wrong, but i certainly do not want any answers given to me, i just need some guidance please.

simo96 · Oct 15, 2011

also- my prob with the cute confusion is that he is answering questions now....he doesnt seem like he's really confused. maybe i should just go with fear. that fits him better.

Silverdragon102, BSN · Oct 15, 2011

Moved to the General Nursing Student Discussions forum

demylenated, BSN, RN · Oct 15, 2011

Sorry if I came across cross, that wasn't my intention... it is imperative that you start using critical thinking skills now... which is why I asked those questions... Which book do you have? I will send you a link to the 2 best ones I have come across... they are a GOD SEND (I am a nurse furthering my degree - so I am a "student" too - but we don't do care plans too often at this level any more).

...isnt following commands and not oriented.. ... after several days he is awake and answers questions but is very angry and abusive to mom and gf.

I don't really see where confusion would fall into the equation. What I read into the above was the "confusion" was acute, and he was basically in a coma - but is awake now and oriented now.

With the foot - even if it ends up being a "lost cause" (never assume anything, he is still acute and it could just be inflammation and swelling causing his foot issues) you still ALWAYS need to do PROM (unless contraindicated) to keep muscles from atrophying. You said it was "weak" so you want him to move it as much as HE is possible of moving it... and then you want to do PROM and ensure skin stays intact. Plus you want to PREVENT DVTs.

If you follow the ABC's I would be MOST concerned with airway - he has atelectasis... so, impaired gas exchange...

Then something re: immobility... then fear or anger, whichever you feel is best in this situation.

demylenated, BSN, RN · Oct 15, 2011

# 1 - FANTASTIC!!! Well worth the money:

http://www.amazon.com/Nursing-Diagnosis-Manual-Individualizing-Documenting/dp/080362221X/ref=sr_1_1?ie=UTF8&qid=1318712323&sr=8-1

# 2 just as good - I'd do and would recommend to own them both!!!

http://www.amazon.com/Nursing-Diagnosis-Handbook-Evidence-Based-Planning/dp/0323071503/ref=sr_1_1?s=books&ie=UTF8&qid=1318712404&sr=1-1

demylenated, BSN, RN · Oct 15, 2011

but im trying to figure out if acute confusion r/t alcohol abuse is a good diagnosis for this patient. or if it's because of a head injury......that's where im confused.

That isn't a bad thought process, but addiction/abuse isn't indicated in the short synopsis you gave... so you're reading into it if you say he is in w/d. This may have been a one night party thing that he does once a month, so w/d might not be an issue. (of course since THC is illegal, most would say it is abuse - yes; but that doesn't mean he'd have w/d).

Do you only need psychosocial, or do you need to come up with a care plan (holistic - everything) for him?

simo96 · Oct 15, 2011

i think the foot is a bit easier.....i feel more confident with that than his anger. i was thinking that it is days out, and maybe he is detoxing?????

these case studies are helping us with the critical thinking. i am in no way a critical thinker at this stage of the game. it is only our 5th clinical week and we are only 2 tests in. it's probably easier said than done considering you are already a nurse, but you need to be a little more compassionate and think back to a time when you didnt have those critical thinking skills yet. trust me, ive always been a straight A student, and being this stressed is very hard for me. it's unlike class ive ever taken. thanks for your help tho!

simo96 · Oct 15, 2011

true. i have nursing diagnosis handbook, 9th edition by ackley and ladwig. very good. i need a n.d regarding his behavior, including goals and 3 interventions.....