help with care plan

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please help! i am a 1st year student. my pt was admitted for anemia, had 3 units of blood administered, was scheduled for colonoscopy the day i was there. he was getting around fine and his blood count was much better. he was taking enema's and other meds to cleanse for his procedure. i have no idea as to what my nursing care plan should be. can somebody please help me with some ideas? thank you

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

care planning is the determination of the patient's nursing problems and the nursing process is the tool we use to do that. the five steps of the nursing process adapted for care planning should be followed in this order:

  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)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • 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

    [*]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)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

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 - the very thing that sticks out when i made a list of the information about this patient that you posted was that the doctor is searching for the cause of the blood loss. 3 units of blood is a lot of blood to replace! the doctor addressed the blood loss first. do you understand why? with the blood volume corrected, the medical plan is now to find what the cause of the blood loss is. that is why the patient is having a colonoscopy. colon cancer is the 2nd or 3rd top cancer in the country. the patient could also have some other disease. in any case, the doctor had reason to think the colon might be the source of the bleeding. what other information were you able to get from the patient's chart that might be helpful here?

  • anemia
  • medical treatment:
    • 3 units of blood administered
    • scheduled for colonoscopy and being prepped

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - since you provided no abnormal data about the patient there can be no problem determination. still, what did the patient know about the upcoming colonoscopy? what teaching needs did he have? what concerns did the patient express about the transfusion or the potential findings of the colonoscopy? this information becomes the source of possible nursing diagnoses. did you check the patient's labwork following the transfusion? are the labs up to normal? you only said they were "better".

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 blood loss aeb

    1. deficient knowledge, diagnostic procedures r/t lack of information aeb [evidence]

      2. 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 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

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