help with care plan

Columnist · Mar 18, 2012

Moved to Nursing Student Assistance as this is a better place to post for help with student assignments. Hopefully you will get some helpful responses here. Good luck with the care plan.

mindlor · Mar 18, 2012

I am first year nursing student and i need help with my care plan.
My pt is an 89 yr old female with COPD, pneumonia, CHF, hypertension, osteoporsis, and incontinence. she had a lot of difficulty ambulating and could barely get to the besdside comode without dsypnea and becoming extremely tired. I have decided to do activity intolerance as one of my dx but i am unsure of how to write it. I have Activity Intolerance R/T the presence of COPD and generalized weakness AEB shortness of breath, weakness, and statements of being tired.

Two things stand out. First you use COPD as the related to. COPD is a medical diagnosis and thus cannot be used. Next, you also use generalized weakness as a related to item and then use weakness as an as evidenced by...this is called a circular diagnosis and will get you a red mark from your teacher.

The best thing you an do to help you with a nursing diagnosis is to have a very rich and detailed assessment database. Please respnd back with all of your assessment findings.

Also, while Activity Intolerance is important, always be thinking of your ABC's when developing your priority diagnosis. In this case, be thinking along the lines of breathing, or maybe even airway, depending upon your assessment details....

nurseprnRN, BSN, RN · Mar 19, 2012

i respectfully beg to differ. copd can be used as a defining characteristic; any medical diagnosis can, according to nanda-i, which is the authority on nursing diagnosis. a medical diagnosis can be a defining characteristic for many nursing diagnosis. what you can't do is say, "i have medical diagnosis x; this means i automatically have nursing diagnosis y."

so. activity intolerance is certainly one possible nursing diagnosis for this patient. it is, indeed, related to her copd; the next part tells your reader what you think it is about her copd that makes it hard for her to be independently mobile. is it that you assessed that she becomes short of breath with the slightest activity (specify). or is she short of breath at rest? is it that her o2 sats drop with any activity? is it that her sats at rest are poor?

mindlor · Mar 19, 2012

well, at my school it would not fly. We can agree to disagree.

NightNurseRN13 · Mar 19, 2012

I would say activity intolerance r/t complex factors AEB dsypnea on exertion, chronic pain, ineffective airway clearance, extremes in age, ineffective alveolar diffusion, etc. etc.

mindlor · Mar 19, 2012

Check out Ackley, section one, pages 5 and 6......

mindlor · Mar 19, 2012

Check out Ackley, section one, pages 5 and 6......

8th Edition

Esme12, ASN, BSN, RN · Mar 19, 2012

ok....first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. let me try to help you. there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) https://allnurses.com/general-nursing...ns-286986.htmlyou can also use the search on this site to lead you to care plans. i have supplied links of examples at the bottom for care plans

are you scratching your head or are you maybe even ready to tear your hair out over how to come up with care plans? here are some words of wisdom from our own beloved daytonite.

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
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)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

you really shouldn't focus too much time on the nursing diagnoses. most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. the nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.

you may also like these resources...... i strongly suggest you budget for a good care plan book as you will need it...alot! i hope this helps.

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

understanding the essentials of critical care nursing

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

cns: problem oriented nursing care plans