Help with care plan

moved to nursing assistance for better response.

What is the patients complaints? What is your assessment.

This is a common mistake many students make they get a diagnosis and try to fit it to the patient. When it is actually the other way around.

The biggest thing (First) a care plan is the assessment. The second is knowledge about the disease process. 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.

The third is a good care plan book. I use ackley: nursing diagnosis handbook, 9th edition and gulanick: nursing care plans, 7th edition

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:

1. 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)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

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.

Just like you need a recipe care to make a cake from scratch. A care plan is your recipe card to caring for your patient and what to look for while you are caring for them.

So your patient has a history of What? and complains about......?.

The construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

• problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
  
• etiology- also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
  
• symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during your assessment of the patient. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals. from our beloved daytonite:RIP
  

• in determining a problem you should always use the nursing process. first, look at the assessment data you have. . .
  
  

care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

What I would suggest you do is to work the nursing process from

step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). The adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming...........and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? If so, now is the time to add them to your list. This is all part of preparing to move onto......

step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

care plan reality: what you are calling a nursing diagnosis (ex: activity intolerance) is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis

Now what information about your patient do you have....

I am also doing a care plan for ineffective tissue perfusion. my patient was admitted to the ER for atrial fibrillation, having chest pain as a primary symptom. he also has diet controlled diabetes. I had difficulty finding a very weak pedal pulse in his right foot after he had a catheter to correct his atrial fibrillation. He had a pulsox of 94%, is a smoker, and had slight 1+ edema in his lower extremities which is slowly going down. I need to write a diagnostic and outcome statement with a goal that I can attain in a 6 hour clinical period. My instructor suggested perfusion as my key problem #1 although i do know what goals I could easily accomplish successfully in 6 hours. Any suggestions?

Maybe I can just make my goal having his pulseox, BP, and pulse within his normal range. I really could use all the help you have to offer. Thanks in advance.

What alteration in tissue perfusion does this patient have? What symptoms does he possess that tell you he is having an alteration in tissue perfusion? Did you mean that the patient had an ablation via the right groin in the EP Lab/Cath Lab? What was this patients pulse to that extremity before the procedure? Is there a complication developing in the femoral artey? What complications can arise for a catherterization utilizing the femoral artery? What else does the patient complain of that signifies alteration in tissue perfusion that is associated with the atrial fib? Wuoud that cause the lower extremity edema if the heart isn't pumping effectively due to the Afib? How does his smoking and diabeties contribute to these factors? Does the patient also have a knowledge deficit?

Nursing Diagnosis

Ineffective Tissue Perfusion: Peripheral, Cardiopulmonary, Cerebral

NANDA-I Definition: Decrease in oxygen resulting in failure to nourish the tissues at the capillary level

Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient, or it can be more acute or protracted with potentially devastating effects on the patient. Diminished tissue perfusion, which is chronic in nature, invariably results in tissue or organ damage or death. Management is directed at removing vasoconstricting factors, improving peripheral blood flow, and reducing metabolic demands on the body.

In practice, patients often present with a combination of causative factors. Therefore this care plan will focus on the general assessment and therapeutic interventions common to many etiologies. The reader is referred to the more specific medical disorder care plans that follow in later chapters. A list of some of these is provided toward the end of this care plan.

Common Related Factors

Impaired transport of oxygen

Interruption in blood flow

Mismatch of ventilation with blood flow

Decreased hemoglobin concentration in blood

Hypoventilation

Hypovolemia

Hypervolemia

Exchange problems

Altered affinity of hemoglobin for oxygen

Defining Characteristics—Peripheral

Weak or absent peripheral pulses

Numbness, pain, ache, claudication in extremities

Skin temperature changes/cool extremities/clammy skin

Shiny skin/loss of hair

Thickened discolored nails

Difference in blood pressure in opposite extremity

Skin color pales on elevation/dependent rubor

Prolonged capillary refill

Bruits

Delayed healing

Altered sensation

Defining Characteristics—Cardiopulmonary

Tachycardia

Dysrhythmias

Hypotension

Tachypnea

Dyspnea

Chest pain

Prolonged capillary refill

Abnormal arterial blood gases

Bronchospasm

Gulanick: Nursing Care Plans, 7th Edition

How do these coordinate with your patient?