Help with Care plan

Daytonite, BSN, RN · Jan 21, 2009

you should be using the steps of the nursing process in the sequence they occur to help you logically organize and guide your care planning here:

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 - this patient has had a c-section and epidural anesthesia. what do you know about these procedures?

the patient went through labor and although the baby had to be removed through an incision, she is now postpartum
- is she breastfeeding?
- having a baby affects these things. . .what does she need to learn?
  - about her breasts
  - about fundus assessment
  - about lochia amount, character or odor
  - about perineal care
  - about urinating
  - about bowel movements
  - about fatigue/energy following labor
  - interacting with her baby
[*]c-section
- there is an incision that needs attention
- complications
  - infection
  - hemorrhage
  - urinary tract trauma
  - thrombophlebitis
  - paralytic ileus
  - atelectasis
[*]epidural anesthesia (complications)
- hypotension
- rash around the epidural injection site
- nausea and vomiting from the opiates administered
- pruritis of the face and neck caused by some epidural narcotics
- respiratory depression up to 24 hours after the epidural
- cerebrospinal fluid leakage and spinal headache from accidental dural puncture
- sensory problems in the lower extremities

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - this is the only patient data (symptom) that i could find in your post. that would be the aeb, or evidence.

pt states her abdomen hurts - this should be more specific and measurable, particularly if medications are given so their effect can be evaluated. the patient should be asked to tell you the intensity of their pain on a scale of 0 to 10.

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 - from the evidence (symptoms) the diagnoses are determined.

acute pain r/t surgical intervention aeb patient statement of abdominal pain of __ on a scale of 0 o 10.

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. interventions are of 4 types:

assess/monitor/evaluate/observe (to evaluate the patient's condition)
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)

--------------------------------------------------------

there are problems with the nursing diagnoses you came up with. they are sequenced incorrectly. "risk for" diagnoses are anticipated problems and are never sequenced before actual problems. i sequenced them correctly. with the exception of the pain diagnosis there is no evidence to support the other two actual nursing problems. all nursing diagnoses are chosen and based upon evidence that supports them. we do not chose nursing diagnoses and then look for evidence to support using them.

activity intolerance r/t delivery and secondary to anethesia administration, surgical incision, and pain.
- please read the definition of this diagnosis if you have a copy of taber's cyclopedic medical dictionary (it's in the appendix) or see this website: activity intolerance - this problem has to do with not having enough energy to do one's adls. it is generally associated with being deconditioned and getting short of breath with activity. if you look at the defining characteristics (signs and symptoms) that nanda has listed for this diagnosis they involve elevated heart and respiratory rates and fatigue. i can see where certain anesthetic agents could cause this. but the presence of an incision? pain? not buying those as the cause of low energy.

[*]pain related to surgical incision aeb pt states her abdomen hurts.

already addressed this above. the pain needs better description.
the actual nanda diagnosis is acute pain.

[*]ineffective coping r/t surgical intervention, perceived loss of birthing experience, and fatigue aeb ???

people who aren't coping correctly aren't able to use help that is around us to get through our difficult circumstances. the "related to" part of these diagnostic statements is what is causing this problem. so, you are saying being cut into by the surgeon is causing this lady not to be able to cope with this birthing experience? that doesn't sound logical. her perceived loss of (i assume you meant) the baby is another cause of this lady not being able to cope with this birthing experience? that doesn't sound logical either. fatigue is listed as a defining characteristic (symptom) of this diagnosis so it can't be an etiology (related factor). people can't cope because of prior learned behaviors and beliefs, fears, threats. what did she say or what odd behavior did she exhibit that led you to believe that she wasn't dealing with this whole experience very well at all? are you sure her fatigue was because of ineffective coping and not because she was just physically tired because of having gone through some hours of labor and anesthesia?
see ineffective coping and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=15

[*]risk for fluid volume deficit r/t blood loss associated with surgery.

was there actual blood loss or not? if there was then there is an actual fluid volume deficit. you do not need to add "with surgery".

[*]risk for infection r/t delivery and secondary to surgical incision.

delivery is not a risk factor for infection. it is too broad of a term and tells us nothing about what has happened to this patient.
risk factors (r/t's) for infection in postpartum mothers are:
- operative procedures (c-section, episiotomy)
- multiple cervical examinations during labor
- labor longer than 24 hours
- extremely early rupture of membranes
- manual extraction of the placenta
- diabetes
- having the urinary bladder catheterized
- anemia (decreased wbc count)
[*]see post #7 on https://allnurses.com/general-nursing-student/help-care-plans-286986.html for directions on how to write interventions for "risk for" diagnoses.

christieb01 · Jan 21, 2009

Thanks Daytonite. I was really hoping you would reply to help me with this. Your advice makes a lot of sense. I feel like I'm starting from scratch every time I have to write one of these. I'm going to take your advice and re-do this plan. Thanks for all the advice you give to students on this site!!

Christie

One question- to modify the risk for infection- the nurse needed to keep her hand inside of the patient (in order to prevent the pressure on the umbilical cord) until the baby could be safely delivered- approx 30 minutes- so the c-section was considered "clean" and not sterile- how can I word this in the diagnosis?

Thanks!

Daytonite, BSN, RN · Jan 21, 2009

How about "manual manipulation (or repeated manual manipulations) of prolapsed umbilical cord prior to C-section"?

christieb01 · Jan 21, 2009

Thanks, sounds much better than what I had written:chuckle