Having trouble with Nursing Diagnosis / Care Plan

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Hello,

I have an assignment I have unfortunately left to the last minute due to the death of my father last week. I am having a great deal of trouble with it, and was wondering if anyone could be of assistance to me.

We must include the following: Assessment, Diagnosis, Planning, Implementation - independent/collaborative, and evaluation.

Here is the patient scenario:

64 year old patient had a total hip arthroplasty due to end stage osteoarthritis 1 day ago. She has a dressing over her right hip incision which is to be changed three times daily. She has been in bed since her surgery. She has not complained, but stays very still and is not moving well in bed.

I know care focus should be on :

Pain

Cognition/ delirium

Respiratory

Cardiovascular

Medications

Anemia

Wound/skin care

Nutrition

Elimination

Mobility/function

* I have a little knowledge on the Braden risk assessment

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Specializes in PICU, Sedation/Radiology, PACU.

I'm very sorry to hear about your father. *hugs*

Shouldn't this situation be an extenuating circumstance that would allow you a few extra days to complete this assignment?

That aside, in your assessment column, pick out the date from the senario that you find pertinent to the patient's health. What problems can you identify? What results are abnormal? Example: pt does not move independantly

How many diagnoses do you need? Choose the diagnoses that affect the patient the most- airway, breathing, circulation, pain, etc. Refer to your texts for the format for a nursing diagnosis. Example; risk for impaired skin integrity r/t immobility.

Planning- identify patient centered, measureable, specific and timed goals. Example: Pt will not have any skin breakdown from admission to discharge.

Interventions- List the things that you, the nurse (independant), and the health care team (collaborative) are going to do to correct/prevent the problem identified in the diagnosis. Example: Independent- Turn patient q 2 hours. Elevate heels with pillows. Collaborative: Physical Therapy to increase indepenant mobility. Multivitamin to ensure adequate supply of nutrients.

Evaluation- how well did your interventions work? Did the patient meet the goals set in the planning stage? Why or why not? What do you need to change about the care plan so the patient can meet the goals?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

i am sooo sorry for your loss.......i lost my dad a couple of years ago and i miss him everyday. there were days i didn't think i'd survive the sadness......but i can tell you it will get better. :hug:

here are some very helpful way to do care plans from some very great an mambers rnwriter and daytonite(rip),

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

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ashleymc: risk for infection could be a diagnosis also

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Sorry about your dad :(

Is there a reason you list cognition over wound care & mobility? Is she really out of it, or just a little? If she's completely bedridden and immobile, I (as a new student, mind you), would consider the risk for pressure wounds pretty high. She's not moving, unable to ambulate. Her surgical wound seems to be well taken-care of.

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Specializes in Medical and general practice now LTC.

moved to the General Nursing Student Discussions forum

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Specializes in LTC, Nursing Management, WCC.
hello,

i have an assignment i have unfortunately left to the last minute due to the death of my father last week. i am having a great deal of trouble with it, and was wondering if anyone could be of assistance to me.

we must include the following: assessment, diagnosis, planning, implementation - independent/collaborative, and evaluation.

here is the patient scenario:

64 year old patient had a total hip arthroplasty due to end stage osteoarthritis 1 day ago. she has a dressing over her right hip incision which is to be changed three times daily. she has been in bed since her surgery. she has not complained, but stays very still and is not moving well in bed.

i know care focus should be on :

pain chronic? acute? thinking d/t surgery?? however not complaining of pain, possible risk for pain, acute

cognition/ delirium why?? i see nothing pointing to this

respiratory does this person have an actual resp problem? e.g. asthma, copd, etc.

cardiovascular what lead you to this?

medications ?? what medications... are you thinking anticoagulants? risk for injury

anemia are there labs that support this? did they recieve a transfusion? was there blood loss?

wound/skin care bingo! think skin integrity impairment, risk for infection

nutrition why?, to me, nonissue unless they have something going on. yes nutrition is very important in wound healing but you can address that in your skin care plan

elimination do they have an elimination problem or a foley or something?

mobility/function biggie! think impaired physical mobility or impaired bed mobility

* i have a little knowledge on the braden risk assessment

sorry about your dad!!

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