Help with care plan

Daytonite, BSN, RN · Apr 15, 2009

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

swelling is also a vague term and for purposes of care planning and evaluation of treatments can be measured by taking a measuring tape and the circumference of the arm and compared to the other arm and then recorded on successive days. swelling is a symptom of inflammation (an -itis), a normal body response when a body is fighting against tissue destruction or an infection (

https://allnurses.com/general-nursing-student/histamine-effect-244836.html

). very little was mentioned about how communication was achieved with this patient. you failed to mention if she was a below the knee or above the knee amputee. communication is a safety issue. psychosocial diagnoses have to do with behavior. can't help you there because there is no assessment information about this patient's behavior. did you talk with the daughters about the patient at all? about the only thing i could suggest might be something along the lines of social isolation because of her physical disabilities or some kind of grieving because of her loss of mobility and confinement to the home as a result of her illness. but you need evidence to support using those diagnoses.

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

you need to look up each of these and find their pathophysiology and their signs and symptoms. you need to be able to match the drugs and treatments that have been ordered by the doctors with the medical problems she has and why they were ordered (for example, the steroids she is receiving). this is going to help you learn about these diseases and how they are treated. it will help deepen what you can learn from having taken care of this patient. you also need to compare the signs and symptoms of these diseases against the signs and symptoms that you found during your physical exam. this is how you will improve your physical exam skills for the next patients you care for. the pathophysiology of many medical diseases can be found in the online merck manual and signs and symptoms as well as the basic medical treatment of many diseases can be found on these websites:

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.

modi · Apr 15, 2009

Wow! Thanks for the help! This gives me alot to look at.

modi · Apr 16, 2009

I've gone over my data and clustered somethings together, for my pyschosocial diagnoses I'm thinking

"Hopelessness r/t diabetes scondary to deteriorating physiologic conditions" does that make sense???

The data used to come up with this is

loss of legs (below thigh)

failure to communicate when hospitalized (speaks no english)

physical inability to take care of herself

present condition pneumonia & osteomyelitus

but more importantly,

with her daughter translating she stated

"she's tired..been through alot"

"pain in her arm is continuous...painful"

"feels weak tired...was strong woman before"

"can't do things for herself"

"wants to go home"

a tear rolled down her face.

Her daughter stated,

"family is tired"

"this has to be it"

"one thing after another it's stressful"

"where she comes from children take in sick parents, they don't put in home"

"it's alot, but this is what they must do"

"father is also getting ill"

With this infor the diagnoses sound good??

Also, goals and interventions will be on mostly, comfort, therapeutic communication, medication???

Daytonite, BSN, RN · Apr 16, 2009

hopelessness r/t diabetes scondary to deteriorating physiologic conditions

diabetes cannot be listed as a related factor this way. it has to be stated it is secondary to something. the deteriorating conditions is ok, but you may list them as secondaries. in your supporting data you list

pneumonia & osteomyelitis

. these are medical diseases and not signs and symptoms of hopelessness. the osteomyelitis is a deteriorating condition. the pneumonia is an acute, temporary condition. re-word this diagnosis to read:

hopelessness r/t deteriorating physical conditions secondary to diabetes and osteomyelitis.

watch your spelling.

the data used to support this diagnosis would be:

loss of legs (below thigh)

(speaks no english)

physically inable to take care of herself

"she's tired..been through alot"

"pain in her arm is continuous...painful"

"feels weak tired...was strong woman before"

"can't do things for herself"

"wants to go home"

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.

her daughter stated,

"family is tired"

"this has to be it"

"one thing after another it's stressful"

"where she comes from children take in sick parents, they don't put in home"

"it's alot, but this is what they must do"

"father is also getting ill"

modi · Apr 17, 2009

Hi Daytonite!!

My professor is not responding to my email, so I'm going to bother you again if you don't mind. I really appreciate the help you have given me.

As for a physioloigical diagnoses.......here is the data collected

dyspnea (is this all-inclusive of labored, shallow breathing and shortness of breath)

skin color: dusky

congestion

Respirtatory sounds: rhonchi and wheezing

fatique

generalized weakness

I figured this would be a respiratory diagnoses but i only see, Risk for Respiratory, which I can't use because she already has respiratory problems. Then I only see Decreased Cardiac Output r/t?? OOOhh..I don't know..just when I think I might have the hang of this ND thing...I hit a brick wall. Activity Intolerance looks good but I need a physiological ....what else...how about Risk for Impaired Skin Integrity r/t bedrest. What do you think??

Or I could get something from this data

Pain in left arm - level 6

edema-left elbow approx 1/2"

dry brittle finger nails possible from lack of circulation

fatique

generalized weakness

I think the respiratory problem is more prevalent.

As far as medication she's taking Lovenox, Coreg, Avelox, Vancomycin, nifedicine,cyclobenzprine, solumerdol( for Arthritis, Percoset and a couple of others for digestion and depression.

Thanks for the help!

modi · Apr 17, 2009

It's me again, I'm currently reading some of your past post on respiratory ( I guess I should of done that before) I'm getting a little clearer, I'm thinking the

Ineffective Airway Clearance r/t increased secretion secondary to pneumonia, is what I should go with.

My patient was not coughing at all would I make, attempt to get pt. to cough (I would word it better) as an intervention?? Why wouldn't she have been coughing..it seems all the other "respiratory posts" their pt were coughing.

We only get a few hours with our client and go in blind, otherwise I would of asked my professor. I love to be able to research before clinical, so I'd know more to look for or ask. Oh well!! Thanks again!

Daytonite, BSN, RN · Apr 17, 2009

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