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Discussion

Help with care plan

I'm doing my very first care plan and i'm so confused. My patient has pancreatic cancer, but she was admitted to the hospital with obstructive jaundice and abdominal pain. my instructor helped me out with a few nursing diagnoses and we only have to pick our priority diagnosis to write a care plan on. Below are some of the diagnoses she helped me come up with. In lecture I've always been told if there isn't an airway issue than pain is always priority, but my clinical instructor says Risk for electrolyte imbalance r/t patient receiving chemotherapeutic medications is my priority but i don't understand how that is true since its a potential problem not an actual problem and her pain is an actual problem. Let me know what you think, am i way off base here?

  • Acute pain r/t biliary stent surgery a.e.b patient rates pain 6 out of 10
  • Risk for electrolyte imbalance r/t patient receiving chemotherapeutic medications
  • Risk for decreased liver function r/t increased bilirubin level of 13 a.e.b yellowing of patient skin and eyes
  • Risk for falls r/t unsteady gait
  • Activity intolerance r/t pain a.e.b patient unable to get out of bed, pain rating 6 out of 10

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    • Featured Replies

    • Acute pain r/t biliary stent surgery a.e.b patient rates pain 6 out of 10
    • Risk for electrolyte imbalance r/t patient receiving chemotherapeutic medications
    • Risk for decreased liver function r/t increased bilirubin level of 13 a.e.b yellowing of patient skin and eyes
    • Risk for falls r/t unsteady gait
    • Activity intolerance r/t pain a.e.b patient unable to get out of bed, pain rating 6 out of 10

    I'll just think out loud and give you a few thoughts about how they are written… It's hard to know the priority without seeing the patient.

    I learned that:

    A surgical procedure can't be a r/t

    Example (I'd even add more info):

    Acute paint r/t trauma and manipulation of tissue secondary to biliary stent placement aeb pt rates 6 out of 10, (moaning, grimacing, guarding)

    You need to put exact chemo med and say "why" it may cause an electrolyte imbalance.

    A risk dx shouldn't have an aeb (so change the liver fx one/and if she has jaundice, I would think she is past the risk and actually has liver impairment)

    You should add more info about the risk for fall (anemia?, activity intolerance?, balance?, pain?… I don't know the patient)

    I think there is more to the activity intolerance one, not usually caused just by pain (your patient sounds like she has enough going on that the pain isn't the only cause). Oxygenation and circulation are usually the two biggest causes of activity intolerance (think what make them get out of breath or worn out from activity)

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    • Experts

    It is impossible to help you with the priority without an assessment....care plans are all about the assessment. tell us your assessment of this patient.

    An at risk diagnosis can supersede an actual diagnosis depending on the likelihood of the patient developing the at risk diagnosis. For examplew: a patient that is receiving thrombolytics (clot busting drugs) is "at risk" for bleeding but the risk of them developing bleeding is very high and something that takes a high priority for the nurse to look out for.

    Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to 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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    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: ADPIE from our Daytonite

    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)

    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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.

    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 is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    Another member GrnTea say this best......

    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

    "Related to" means "caused by," not something else.

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    • Author

    Thank you so much! I'm totally lost here, they do not prepare us much for these care plans. Surprisingly my instructor has helped/approved all of these diagnoses, but it looks like i need to work on them a bit. I think the problem is my group got screwed at our clinicals (the unit shut down and we missed an entire week) so i think she just wants us to turn something in at this point and she doesn't want us to stress too much because this is our first care plan and we aren't even going to be able to implement them.

    as far as assessment data, i don't have a ton of information mostly just chart data which is the problem. she is very sick and couldn't/didn't want to spend a lot of time with me and we didn't have time to get a different patient for me to assess. I really feel screwed out of my clinical experience.

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    • Acute pain r/t biliary stent surgery a.e.b patient rates pain 6 out of 10
    • Risk for electrolyte imbalance r/t patient receiving chemotherapeutic medications
    • Risk for decreased liver function r/t increased bilirubin level of 13 a.e.b yellowing of patient skin and eyes
    • Risk for falls r/t unsteady gait
    • Activity intolerance r/t pain a.e.b patient unable to get out of bed, pain rating 6 out of 10

    It is a HUGE fallacy that "risk for" diagnoses are somehow less "actual" and therefore less important. This is absolutely not true. If you look at the NANDA-I 2012-2014 (which you had better get, if you don't have it already, only $29 ($25 for your Kindle or iPad Kindle reader app) and free two-day shipping at Amazon) you will discover that there is an entire section on safety, and almost all of those diagnoses are "risk-for." I realize that it is very hard for students to be able to see the big picture, but that's what you're in school for. :) I

    t's not a hard-and-fast rule that pain is more important than everything besides airway. A lot of the time for any given individual, that might in fact be true, but you cannot just automatically assume it. As my friend and colleague Esme says, you have to learn to look at THIS patient to learn what is most important at any given time.

    Now, as to your choices for diagnoses, let's review something very important.

    To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors-- but these are specified in NANDA-I too.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle or iPad at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty.

    I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. Sometimes they're out of date, too-- NANDA-I is reissued and updated q3 years, so if your "handbook" is before 2012, it may be using outdated diagnoses.

    We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for. It is totally unacceptable to make up a nursing diagnosis. This is because we are trying so hard to implement evidence bases for our practice, and the NANDA-I nursing diagnoses have met those tests. (Interestingly, every edition has a list of NDs that have been removed for lack of evidence after further research.)

    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

    1, health promotion (teaching, immunization....)

    2, nutrition (ingestion, metabolism, hydration....)

    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

    5, perception and cognition (attention, orientation, cognition, communication...)

    6, self-perception (hopelessness, loneliness, self-esteem, body image...)

    7, role (family relationships, parenting, social interaction...)

    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

    10, life principles (hope, spiritual, decisional conflict, nonadherence...)

    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

    12, comfort (physical, environmental, social...)

    13, growth and development (disproportionate, delayed...)

    So, looking at your diagnoses, the first three are correct. in form and components.

    However, looking at "risk for impaired (not "decreased") liver function, p. 183, having an increased bili level is evidence of impaired liver function, not a risk factor for it. See that? The only factors for impaired liver function are, well, things that injure a liver: hepatotoxic meds (statins, acetaminophen, e.g.), HIV coinfection, susbtance abuse (e.g., alcohol, cocaine), and viral infection (e.g., hepatitis A, B, or C, Epstein-Barr). So your patient may have been at risk for impaired liver, but it looks to me as if her liver is already impaired if she has an elevated bili and jaundice. There is no nursing diagnosis for liver dysfunction-- which in your patient may be related to blocked biliary tree from her cancer, a medical diagnosis-- making that diagnosis is a medical thing, because it's a medical diagnosis.

    "Risk for falls" includes alterations in gait as one of the risk factors, so you're good there. What else might make her at higher risk for falling? Confusion? Delirium? Meds? High bili? High ammonia levels? Observe YOUR patient. it's always OK to have more than one reason for a problem.

    "Activity intolerance" includes in its possible defining characteristics "exertional discomfort," which may or may not be pain; defining charateristics are evidence, not causes. Related factors for this diagnosis, the causes, are (only) bed rest, generalized weakness, imbalance between O2 supply and demand, immobility, and sedentary lifestyle. So, if you think she has activity intolerance, look at that list and say what from that list causes pain in her, and then add, "...as evidenced by discomfort on exertion (pain 6/10)."

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    Is your clinical instructor grading your care plan? If so, you may just want to take her advice, unless your care plan can prove to her that pain is more important than potential for electrolyte imbalances. Electrolyte maintenance is a high priority for oncology nursing, especially as imbalances can lead to cardiac dysrhythmias, seizures, etc. at their worst. However, if the patient has no other immediate risk for imbalances (vomiting, diarrhea, dehydration) or electrolytes are still WNL - the pain should take priority.

    Great job on those care plan ideas! The only thing is that #3 is not a risk. Any time there are aeb symptoms, it is no longer a risk, but an actual problem. :) Hope that helps!

  • Quote
    • Experts
    Thank you so much! I'm totally lost here, they do not prepare us much for these care plans. Surprisingly my instructor has helped/approved all of these diagnoses, but it looks like i need to work on them a bit. I think the problem is my group got screwed at our clinicals (the unit shut down and we missed an entire week) so i think she just wants us to turn something in at this point and she doesn't want us to stress too much because this is our first care plan and we aren't even going to be able to implement them.

    as far as assessment data, i don't have a ton of information mostly just chart data which is the problem. she is very sick and couldn't/didn't want to spend a lot of time with me and we didn't have time to get a different patient for me to assess. I really feel screwed out of my clinical experience.

    what are her labs? What did she say? You say she is very sick...what makes you say that?
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    • Author

    Thank you for telling me about the book. I have a list of approved diagnoses that school gave me but i was unaware that the book existed i will definitely be getting it!

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    • Author

    Bilirubin- 13 BUN- 1.7 PT- >19.2 WBC-9.2 RBC-3.09 Hgb-11

    Hct- 32.6 MVC-105.5 Platelets-103 sodium-138 potassium-4.2 Chloride-106 Creatinine-0.53 albumin 1.7 calcium-7.5 AST-99 ALT-59 Blood glucose (bedside fingerstick)-260 total protein-4.8

    there were others in her chart but my instructor told me to only write these down. once again i'm so lost. And i mean sick as in she has cancer and going through chemo which is making her nauseated, she was only a few hours post op when i saw her and she was very tired, in pain and just didn't want to be bothered so i didn't spend a lot of time with her to really be able to figure out much. Just based on how she looked (to me) was fatigued, yellow, and frail.

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    • Author

    yes my instructor is grading this. it doesn't actually get a percentage grade, its just pass fail. My school seems so unorganized! I'm frustrated and not at all prepared for this care plan. this is die tomorrow and i will be getting another one to do tomorrow that is due sunday.

    She wasn't currently vomiting or having any diarrhea but she is on antiemetics. and when i arrived for my clinical she was already on dextrose 5% & 0.9 NaCl w/Kcl 40 mEq/L so i'm guessing she was already being treated for an imbalance....ugh

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    It will get better. If you knew how to do it perfectly already, you wouldn't be in school. :) Learning how, that's why you're there. Glad we could help. There are always a LOT of care-plan-related questions here and both Esme and I tend to repeat ourselves a bit, though we do, like with care plans, try to customize it for the individual situation. :) So look around and find some more threads about care planning and see what you can pick up. It's a skill you can learn. :)

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    • Experts
    Bilirubin- 13 BUN- 1.7 PT- >19.2 [/b][/size]WBC-9.2 RBC-3.09 Hgb-11

    Hct- 32.6 MVC-105.5 Platelets-103 sodium-138 potassium-4.2 Chloride-106 Creatinine-0.53 albumin 1.7 calcium-7.5 AST-99 ALT-59 Blood glucose (bedside fingerstick)-260 total protein-4.8

    there were others in her chart but my instructor told me to only write these down. once again i'm so lost. And i mean sick as in she has cancer and going through chemo which is making her nauseated, she was only a few hours post op when i saw her and she was very tired, in pain and just didn't want to be bothered so i didn't spend a lot of time with her to really be able to figure out much. Just based on how she looked (to me) was fatigued, yellow, and frail.

    You are confused because you aren't being lead or taught. Without the criteria and detail or each diagnosis the list will do you NO GOOD.

    Each nursing diagnosis has a definition that you patient must fit into in order to use it. Each diagnosis has a list of "symptoms" or "taxotomy" that applies and your patient must have at lest one in order for you to use that diagnosis. without a care plan book like the NANDA I....you will find it impossible to do care plans. I use the NANDA I and Ackley: Nursing Diagnosis Handbook, 10th Edition. Grntea also has book suggestions that I think you need to look into to make you life livable in school.

    For example Risk for Bleeding : NANDA-IDefinition

    At risk for a decrease in blood volume that may compromise health

    Risk Factors: (what makes it likely that your patient may experience this)

    Aneurysm; circumcision; deficient knowledge; disseminated intravascular coagulopathy; history of falls; gastrointestinal disorders; impaired liver function; inherent coagulopathies; postpartum complications; pregnancy-related complications; trauma; treatment-related side effects.

    Your patient has at least 2, if not 3, of these. You know this because they have

    INR-> 1.7, PT- >19.2, Platelets-103, Bilirubin- 13, AST-99 ALT-59
    So your patient is at risk for bleeding as they have no active bleed as of right now....but they can easily have an issue due to the liver disease/pancreatic cancer/abnormal coagulation studies/low platelet count.

    So...your patient is at risk for Bleeding related to impaired liver function, pancreatic cancer/chemo, and abnormal coagulation studies. There is no AEB because they are not actively bleeding.

    Now if they started bleeding that is an actual diagnosis and you would look for diagnosis that apply to active bleeding like loss of circulating blood volume....(volume deficit)... and decreased cardiac output...(hypotension)

    Your patient has Nausea...NANDA-I Definition

    A subjective, unpleasant, wavelike sensation in the back of the throat, epigastrium, or the abdomen that may lead to the urge or need to vomit

    Now this is an active problem so you have defining characteristics (symptoms your patient must display) that apply : Aversion to food; gagging sensation; increased salivation; increased swallowing; report of nausea; sour taste in mouth

    Your patients nausea must be related to (R/T) because of at least ONE (or more) of these things.

    Related Factors (r/t):

    Biophysical

    Biochemical disorders (e.g., uremia, diabetic ketoacidosis, pregnancy); esophageal disease; gastric distention; gastric irritation; increased intracranial pressure; intraabdominal tumors; labyrinthitis; liver capsule stretch; localized tumors (e.g., acoustic neuroma, primary or secondary brain tumors, bone metastases at base of skull); meningitis; Ménière’s disease; motion sickness; pain; pancreatic disease; splenetic capsule stretch; toxins (e.g., tumor-produced peptides, abnormal metabolites due to cancer)

    Situational

    Anxiety; fear; noxious odors; noxious taste; pain; psychological factors; unpleasant visual stimulation

    Treatment-Related

    Gastric distention; gastric irritation: pharmaceuticals

    So...your patient has Nausea R/T gastric irritation, chemotherapy and abnormal metobolites due to pancreatic cancer AEB (as evidenced by) patient complaint of nausea, weight loss/frailty, and poor nutrition status.

    You know your patient has Imbalanced Nutrition: less than body requirements because of their labs

    albumin 1.7, calcium-7.5, total protein-4.8
    Imbalanced Nutrition: less than body requirements: NANDA-I Definition

    Intake of nutrients insufficient to meet metabolic needs

    Defining Characteristics

    Abdominal cramping; abdominal pain; aversion to eating; body weight 20% or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyperactive bowel sounds; lack of food; lack of information; lack of interest in food; loss of weight with adequate food intake; misconceptions; misinformation; pale mucous membranes; perceived inability to ingest food; poor muscle tone; reported altered taste sensation; reported food intake less than RDA (recommended daily allowance); satiety immediately after ingesting food; sore buccal cavity; steatorrhea; weakness of muscles required for swallowing or mastication

    Related Factors (r/t)

    Biological factors; economic factors; inability to absorb nutrients; inability to digest food; inability to ingest food; psychological factors

    So your patient has Imbalanced Nutrition: less than body requirements (related to) R/T nausea AEB poor food intake and albumin 1.7, calcium-7.5, total protein-4.8

    Do you see where this is going?

    Check out what these labs mean...Platelet Count: The Test Look up liver failure and pancreatic cancer.....find out what happens.

    I here other ND that apply to your patient.

    Acute Pain: due to the imflammation of tissues from surgery

    Risk for unstable blood Glucose level how does the malfunctioning pancreas affect this?

    Acutal diagniosis supreceed an at risk for diagnosis in MOST caese however in this case the risk for bleeding is significant when looking a the labs nd would cost this patient her life.

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    • Experts

    Now how do you decide priority? a simplistic way to look at it is what will kill them first.

    Most program support Maslow's Hierarchy of Needs.

    This hierarchy suggests that people are motivated to fulfill basic needs before moving on to other, more advanced needs. This hierarchy is most often displayed as a pyramid. The lowest levels of the pyramid are made up of the most basic needs, while the more complex needs are located at the top of the pyramid. Needs at the bottom of the pyramid are basic physical requirements including the need for food, water, sleep, and warmth. Once these lower-level needs have been met, people can move on to the next level of needs, which are for safety and security.

    As people progress up the pyramid, needs become increasingly psychological and social. Soon, the need for love, friendship, and intimacy become important. Further up the pyramid, the need for personal esteem and feelings of accomplishment take priority. Maslow emphasized the importance of self-actualization, which is a process of growing and developing as a person in order to achieve individual potential.

    Hierarchy of Needs

    [h=3]Five Levels of the Hierarchy of Needs.....[/h] There are five different levels in Maslow’s hierarchy of needs:

    1. Physiological Needs
      These include the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.

    2. Security Needs
      These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health care, safe neighborhoods, and shelter from the environment.

    3. Social Needs
      These include needs for belonging, love, and affection. Maslow described these needs as less basic than physiological and security needs. Relationships such as friendships, romantic attachments, and families help fulfill this need for companionship and acceptance, as does involvement in social, community, or religious groups.

    4. Esteem Needs
      After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.

    5. Self-actualizing Needs
      This is the highest level of Maslow’s hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.

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