Help with Care Plan Needed

Imafloat, BSN, RN · Nov 4, 2008

hi everyone,
so i have been working on a care plan and i am just not quite sure if i am going in the right direction. i'll share what i have thus far, if anyone could give input on what i have and what i'm missing that would be wonderful!
case study:
-the patient is 79-years-old and lives in ltc.
-non-weight bearing, assistance with adl's
-hx of recurrent uti's caused by mrsa (received long-term antibiotic therapy)
-a&o x 1
-weak
-drey skin and mucous membranes
-indwelling catheter
-dark, concentrated amber urine
-temp. 101.3f
-p 92, r 28, bp 142/80
-stage iii ulcer on sacrum
-grimacing, restless, moaning when asked level of pain
i had to come up with 4 nursing interventions and here is what i have:
acute pain
supporting data:
-increased respirations
-increased bp
-grimacing
-moaning
-restless
deficient fluid volume
supporting data:
-concentrated dark amber urine
-weakness
-dry skin and mucous membranes
-increased body temperature
-a&o x 1
risk for infection
supporting data:
-chronic uti's and mrsa
-broken skin (stage iii ulcer)
-living in ltc
-catheterization - invasive procedure
-tissue destruction (stage iii ulcer)
imparied tissue integrity
supporting data: (i'm having trouble coming up with data for this)
-stage iii ulcer on sacrum
-fluid volume deficit
-impaired physical mobility
another question i have with this is in prioritizing. i know the risk for infection will be 4th, and pain will probably be first. but both deficient fluid fluid volume and impaired tissue integrity are physiological needs so i'm not sure which would go first.
any help would be wonderful! thanks in advance!

you said you have to come up with 4 nursing interventions, yet you listed nursing diagnoses. i want to make sure you do your assignment properly.

Daytonite, BSN, RN · Nov 4, 2008

here's what i come up with. . .

step 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

stage iii ulcer on sacrum
hx of recurrent uti's caused by mrsa
indwelling catheter

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

79 years old
a&o x 1
dry skin and mucous membranes
dark, concentrated amber urine
temp. 101.3 f
respirations 28
weak
non-weight bearing
grimacing
restless
moaning when asked level of pain
assistance with adl's

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

deficient fluid volume r/t ??? aeb dry skin and mucous membranes and dark, concentrated amber urine, elevated temperature of 101.3 f and weakness
hyperthermia r/t infectious process aeb elevated temperature of 101.3 f and respirations of 28
impaired physical mobility r/t ??? aeb non-weight bearing
acute pain r/t ??? aeb grimacing, restless and moaning when asked level of pain
(bathing/hygiene, dressing/grooming. feeding, toileting) self-care deficit(s) r/t ??? aeb [assistance with adl's needs to be more specific]
impaired tissue integrity r/t pressure, fluid deficit and impaired physical mobility aeb stage iii ulcer on sacrum
risk for injury r/t altered mental status [the risk is for fall or accidentally pulling out the foley - interventions would be to prevent these from happening]

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions are the actions you will take to modify, or change, the effect caused by a problem - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem

goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
- improve the problem or remedy/cure it
- stabilize it
- support its deterioration
[*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html
[*]interventions are of four types
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
  - note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
  [*]care/perform/provide/assist (performing actual patient care)
  [*]teach/educate/instruct/supervise (educating patient or caregiver)
  [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

for example, hyperthermia r/t infectious process aeb elevated temperature of 101.3 f.

goal:

maintain oral temperature below 99.6 f.

interventions:

assess the patient for flushed skin, diaphoresis, chills, restlessness, lethargy, tachycardia and tachypnea.
monitor an elevated temperature every 2 hours; monitor vital signs every 4 hours.
administer antipyretics as prescribed.
take temperature 30-60 minutes after an antipyretic has been given to assess its affect.
use the same site and deice to assess the temperature for consistency.
add linens and blankets to the bed to help maintain comfort and body temperature.
encourage the patient to drink fluids such as water, juice, tea, broth and sports drinks to replace lost fluid and nutrients.
notify the physician if the fever goes above 104 f or there is a change in the patient's mental status.

here are the problems with your diagnoses and interventions: everything is supporting data--none of it is an intervention.

acute pain

supporting data:

-increased respirations

-increased bp -a b/p of 140/80 is considered normal, so 142/80 is barely elevated

-grimacing

-moaning

-restless

deficient fluid volume

supporting data:

-concentrated dark amber urine

-weakness

-dry skin and mucous membranes

-increased body temperature

-a&o x 1 - i don't know that i would say that oriented to name only is evidence of deficient fluid volume. how do we know this isn't this lady's normal state of mind?

risk for infection - its a good bet she already has an infection with a fever of 101.3f

supporting data:

-chronic uti's and mrsa

-broken skin (stage iii ulcer)

-living in ltc

-catheterization - invasive procedure

-tissue destruction (stage iii ulcer)

impaired tissue integrity - the stage iii ulcer can be described by breaking it down into the description of a stage iii ulcer unless you have actual measurements that were taken.

supporting data: (i'm having trouble coming up with data for this)

-stage iii ulcer on sacrum

-fluid volume deficit

-impaired physical mobility

another question i have with this is in prioritizing.

prioritizing can be done by maslow's hierarchy of needs. you may also want to ask your instructors if there are some things they consider important to be prioritized first over maslow.

http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs

physiological needs (in the following order)
- the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
- the need for food and water
- the need to eliminate and dispose of bodily wastes
- the need to control body temperature
- the need to move
- the need for rest
- the need for comfort

[*]safety and security needs (in the following order)

safety from physiological threat
safety from psychological threat
protection
continuity
stability
lack of danger

[*]love and belonging needs

affiliation
affection
intimacy
support
reassurance

[*]self-esteem needs

sense of self-worth
self-respect
independence
dignity
privacy
self-reliance

[*]self-actualization

recognition and realization of potential
growth
health
autonomy

dmaccnursing_student · Nov 4, 2008

Sorry, I meant four nursing diagnoses :) :bowingpur

dmaccnursing_student · Nov 4, 2008

So I have been working on re-doing my nursing diagnoses (thanks for the help :) ) and I am trying to reprioritize them. Here is what I have:

1) Deficient fluid volume (because you can't live without water)

2) Acute Pain (physiological comfort issue)

3) Impaired tissue integrity (another physiological problem)

4) Risk for Injury

Let me know what you guys think - I hope I have it right this time. I tried to use Maslow's but I sometimes just confuse myself and think WAY too far into it! :)

Thanks again!

Daytonite, BSN, RN · Nov 5, 2008

deficient fluid volume (actual physiological need for fluid)
acute pain (actual physiological need for comfort)
impaired tissue integrity (actual safety need for protection)
risk for injury (anticipated physiological need for safety and protection)