Help with care plan

a care plan is a list of the patient's nursing problems (nursing diagnoses) and strategies (nursing interventions) to do something about them. to accomplish this we use the nursing process to not only help us organize our (critical) thinking, but to help us sequence the events that take place in this process.

step 1 assessment - the entire plan of care is based on assessment findings, so this first step is the most important activity. your assessment activity is important because when you find things that deviate from normal they, ultimately, will become the criteria by which you will diagnose their nursing problems. therefore, it is important that you recognize when something is abnormal and describe it as thoroughly as you can. assessment consists of:

• a health history (review of systems) - this is information from the patient's past and could be supplied from many different sources. see this thread: https://allnurses.com/nursing-student-assistance/help-preparing-clinical-227507.html - help preparing for clinical day! - it lists all the important information you need to gather from the patient's record. this is a 79 year old female who has been hospitalized for pneumonia. she's a bilateral amputee and has a long history of arthritis. she is married and speaks no english.
  
• performing a physical exam - i have many questions about the physical exam information you listed. this patient was admitted for pneumonia yet i saw no information about a respiratory assessment: respiratory rate, symmetry and use of muscles when breathing, lung sounds, presence of cough or sputum, presence of chest pain. patients with pneumonia may have any of these symptoms: hacking, painful and usually productive cough, rapid, shallow respirations, chills, headache, fever, dyspnea, pleuritic chest pain, grunting respirations, nasal flaring, decreased breath sounds, crackles and rhonchi, cyanosis, tachypnea, tachycardia and yet you mention nothing about any of these! to say "she is congested" is not good enough information to develop a care plan from. neither is "she has pain" and i suspected you meant it was in the left arm and elbow because of the osteomyelitis. but what about her arthritis? does she have pain from the arthritis? where? pain assessment involves determining:
  
  
  
  • where the pain is located
    
  • how long it lasts
    
  • how often it occurs
    
  • a description of it (sharp, dull, stabbing, aching, burning, throbbing)
    
  • having the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain - for this patient who cannot speak english, using something like the wong-baker faces pain rating scale for her to describe her pain: http://www.mdanderson.org/pdf/pted_painscale_faces.pdf
    
  • what triggers the pain
    
  • what relieves the pain
    
  • observe their physical responses
    
    • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
      
    • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
      
    • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
      

• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - there are a lot of self-care issues (eating, bathing and dressing), but they are not described. and, its great that her two daughters show up to help her, but what happens if she needs help and he daughters aren't there? what if she needs help at 3am? or at 6am if they are stuck out on the freeway (we get tie ups on the freeways here that can make you an hour or two late to your destination)? do we just ignore her? how does she get around?
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this patient has the following medical diseases:
  
  • pneumonia
    
  • diabetic (type i or ii?)
    
  • bilateral amputee (ak or bk?)
    
  • arthritis (what type?)
    
  • osteomyelitus in left elbow
    

• merck manual of diagnosis and therapy
  http://www.merck.com/mrkshared/mmanual/sections.jsp
  
  
• medicine net diseases & conditions a to z index
  http://www.medicinenet.com/diseases_and_conditions/article.htm
  
  
• web md index list of medical conditions
  http://www.webmd.com/a_to_z_guide/health_topics.htm
  
  
• family practice notebook (use search box and input a disease)
  http://www.fpnotebook.com/index.htm
  
  

• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking- look at the side effects of the specific steroids the patient is on. what other medications and treatments have been ordered?
  

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

• she is congested - i cannot make a nursing diagnosis from this
  
• arm is swollen - i cannot make a nursing diagnosis from this
  
• she has pain (where?)
  
• speaks no english
  
• her two daughters come to the hospital four times a day to make sure she eats, gets washed and changed
  
• she and her 84 year old husband live with her daughter and have a care giver 8-10 (hours?) a day
  

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 -

• there should be at least one respiratory diagnosis since this is a lady with pneumonia, but since there is no evidence to support a diagnosis. . .
  
• there should probably be impaired physical mobility r/t amputation and pain aeb ???
  
• feeding self-care deficit r/t ??? aeb ???
  
• bathing/hygiene self-care deficit r/t ??? aeb ???
  
• dressing/grooming self-care deficit r/t ??? aeb ???
  
• acute pain r/t inflammation of lungs aeb [any chest pain?]
  
• chronic pain r/t inflammation of large joints and the bone and tissue of left arm aeb ???
  
• impaired verbal communication r/t language barrier aeb inability to speak the language of caregivers
  

step #3 planning (write measurable goals/outcomes and nursing interventions) - now you begin to add nursing interventions for the aeb items that support the diagnoses. sometimes your interventions can target the related factors (r/t items) but not very often when the diagnoses are physiological ones since disease is mostly treated by the physicians and they often can't cure chronic disease.

hopelessness r/t diabetes scondary to deteriorating physiologic conditions

the data used to support this diagnosis would be:

this stuff below is not about the patient. . .i know it is terribly sad, but do not include it with this hopelessness diagnosis. these are caregiver role strain r/t complexity and amount of caregiving activity.

I don't know what list of nursing diagnoses you are looking at. I know the NANDA nursing diagnoses.

Dyspnea, rhonchi and wheezing and dusky skin coloring would be symptoms of Ineffective Airway Clearance because of the exudate in the alveoli secondary to the pneumonia. Congestion is too broad of a term to use. Look dyspnea up in a medical dictionary to learn what it means.

• Ineffective Airway Clearance R/T exudate in the alveoli secondary to the pneumonia AEB dyspnea, rhonchi and wheezing and dusky skin coloring
  

The fatigue and generalized weakness are symptoms of Activity Intolerance because of an imbalance between oxygen supply and demand.

• Activity Intolerance R/T imbalance between oxygen supply and demand AEB fatigue and generalized weakness