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.
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.
How does a doctor diagnose?
He/she does (hopefully) a thorough medical history and physical examination first. Surprise! We do that too! It's part of step #1 of the nursing process. Only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. Each medical diagnosis has a defined list of symptoms that the patient's illness must match. Another surprise! We do that too! We call it "critical thinking and it's part of step #2 of the nursing process. The NANDA taxonomy lists the symptoms that go with each nursing diagnosis.
Steps of the Nursing Process:
Assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)
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. Why? Because as a working RN, you will be using that method many times a day at work to resolve all kinds of issues and minor riddles that will present themselves. That is what you are going to be paid to do. Most of the time you will do this critical thinking process in your head. For a care plan you have to commit your thinking process to paper. And in case you and any others reading this are wondering why in the blazes you are being forced to learn how to do these care plans, here's one very good and real world reason: because there is a federal law that mandates that every hospital that accepts medicare and medicaid payments for patients must include a written nursing care plan in every inpatient's chart whether the patient is a medicare/medicaid patient or not. If they don't, huge fines are assessed against the facility.
You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids.
Simple Example
Steps One - Five
You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "what's wrong?" you're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it. A huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. What you have just done is step #1 of the nursing process--performed an assessment.
You determine that you have a flat tire. You have just done step #2 of the nursing process--made a diagnosis.
The little squirrel starts running like crazy in the wheel up in your brain. "What do I do?," you are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. Good thing you took that class in how to do simple maintenance and repairs on a car! You have just done step #3 of the nursing process--planning (developed a goal and intervention).
You get the jack and spare tire out of the trunk, roll up your sleeves and get to work. You have just done step #4 of the nursing process--implementation of the plan.
After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive. Good. Everything seems fine. The spare tire seems to be OK and off you go and on your way. You have just done step #5 of the nursing process--evaluation (determined if your goal was met).
Can you relate to that? That's about as simple as I can reduce the nursing process to. But, you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.
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 (every NANDA nursing diagnosis has a definition).
Definition: insufficient physiological or psychological energy to endure or complete required or desired daily activities
(does this sound like your patient's problem?)
Defining Characteristics (symptoms): abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness
Related Factors (etiology): bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle.
I've just listed above all the NANDA information on the diagnosis of activity intolerance from the taxonomy. Only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.
In order to choose nursing diagnoses, you also need to have some sort of nursing diagnosis reference. There is some free information on the internet but it is limited to about 75 of the most commonly used nursing diagnoses.
One more thing...
Care Plan Reality
Nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. They are all linked together with each other to form a nice related circle of cause and effect.
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.
Hi, I need some help with a nursing care plan. I was in clinicals and was assigned to a patient with a sigmoid colectomy with partieal cystectomy. This patient has a past history of CAD, Diverticulitis, HTN, IDDM, and VAG abscess. I need at least 4 diagnosis. Plus I need some labs on this patient. I have some lab results but I didn't have time to get them all. I really do need some help on this one. Thanks!!!!
Specializes in med/surg, telemetry, IV therapy, mgmt.
Hi, I need some help with a nursing care plan. I was in clinicals and was assigned to a patient with a sigmoid colectomy with partieal cystectomy. This patient has a past history of CAD, Diverticulitis, HTN, IDDM, and VAG abscess. I need at least 4 diagnosis. Plus I need some labs on this patient. I have some lab results but I didn't have time to get them all. I really do need some help on this one. Thanks!!!!
You must provide a list the patient's symptoms in order for me to help you. What you have above are the medical diagnoses.
Alright, so I'm finally breaking down and coming here for help.
Last week I had a patient with dementia. He was noncommunicative; however, he responded to auditory stimuli, and was able to respond with a "yes" or "no" to pain (denied pain). The nursing home brought him to the hospital with abdominal distention r/t fecal impaction. The impaction was removed, stool softeners/enemas/laxatives/bulking agents were given and he now has constant diarrhea. He also has an unstageable pressure ulcer of the sacral area and is immobile. He is fed through a PEG tube (I have no information that explains the need for the feeding tube or when it was placed).
My problem is coming up with nursing diagnoses for this concept map. I already have adult failure to thrive, impaired nutrition:less than, insomnia, impaired physical mobility, and impaired skin integrity. I also added r isk for impaired environmental interpretation syndrome (risk because I could not get him to talk to assess his orientation to person, place, time, circumstance) and risk for deficient fluid volume. I just feel like I'm missing a lot of other diagnoses and that some of the ones common for dementia do not apply to this patient (or do but how am I to know without being able to properly assess).
If anyone could provide me with some assistance it would be greatly appreciated. :]
Specializes in med/surg, telemetry, IV therapy, mgmt.
alright, so i'm finally breaking down and coming here for help.
last week i had a patient with dementia. he was noncommunicative; however, he responded to auditory stimuli, and was able to respond with a "yes" or "no" to pain (denied pain). the nursing home brought him to the hospital with abdominal distention r/t fecal impaction. the impaction was removed, stool softeners/enemas/laxatives/bulking agents were given and he now has constant diarrhea. he also has an unstageable pressure ulcer of the sacral area and is immobile. he is fed through a peg tube (i have no information that explains the need for the feeding tube or when it was placed).
my problem is coming up with nursing diagnoses for this concept map. i already have adult failure to thrive, impaired nutrition:less than, insomnia, impaired physical mobility, and impaired skin integrity. i also added r isk for impaired environmental interpretation syndrome (risk because i could not get him to talk to assess his orientation to person, place, time, circumstance) and risk for deficient fluid volume. i just feel like i'm missing a lot of other diagnoses and that some of the ones common for dementia do not apply to this patient (or do but how am i to know without being able to properly assess).
if anyone could provide me with some assistance it would be greatly appreciated. :]
even if you never knew any of the patient's medical diagnoses, nursing care planning is based on what we learn about the patient's response to their situation. nursing diagnoses are merely labels for nursing problems. they are based upon abnormal assessment data that is obtained during the nurse's investigation of the patient. assessment consists of:
a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications they are taking
from what you posted, this patient has the following abnormal data:
fed through a peg tube - does this mean he is incapable of swallowing at all? is he at an abnormal weight? too small for his height indicating he isn't getting enough nutrition (not likely with a peg tube in place)?
abdominal distention r/t fecal impaction (impaction was removed, stool softeners/enemas/laxatives/bulking agents were given and he now has constant diarrhea) - is the abdominal distension resolved? is the diarrhea still going on? is he incontinent? bowel incontinence? bladder incontinence, too?
immobile - describe the immobility. what extremities can he move or not move? is he bedridden? is this causing skin and circulation problems?
unstageable pressure ulcer of the sacral area - all ulcers are stageable which is why we do assessments, take measurements of these wounds and describe them. see
[*]dementia - what are this patient's symptoms of the dementia beside not speaking? dementia usually involves memory deficits, impaired thinking, disorientation and behavioral problems. patients with dementia usually require lots of assistance with their adls
[*]noncommunicative, but responded with a "yes" or "no" to pain (denied pain) - so how does this patient make his needs known? if he gets thirsty or wants to change position in bed--how does he let the nurses know?
assessment is a skill that will take a long time to master. you also need to look up medical conditions like dementia to find the pathophysiology going on to help you understand the related factors of the nursing diagnoses you will use. adult failure to thrive is not a diagnosis i would use unless the patient is showing declining weight loss which can only be found in his chart over successive months, or if the physician has stated this. listing adult failure to thrive with impaired nutrition: less than body requirements and impaired physical mobility is redundant. read the definitions of each of these diagnoses.
i do not understand your use of risk for impaired environmenal interpretation syndrome. this diagnosis is used with patients who are confused and out of touch with reality. it is used when there are safety needs. if interventions are needed for the confusion, chronic confusion should be used instead. (1) saying "risk for" means this would be a potential problem. (2) if the patient has this problem, what is his confusion putting him in danger of? if you could not get patient to talk, he simply has impaired verbal communication which is not uncommon with people who have progressively deteriorating dementia.
i will often concede that patient's on tube feedings are at risk for deficient fluid volume. bet you don't know why. they don't get enough supplemental water (risk for deficient fluid volume r/t inadequate water administration). nurses, for some reason, don't think to throw glasses of water down theses tubes throughout the day unless it is written down somewhere on a mar.
other nursing diagnoses to consider are
diarrhea (could be related to high osmolarity of tube feeding formula)
total incontinence
impaired physical mobility
impaired skin (or tissue) integrity r/t pressure [assessment will determine if you use skin or tissue as the diagnosis]
First of all, thank you very much for your informative post.
After reviewing the chart I would say the PEG tube was placed due to this patient's inability to swallow. And that was interesting about not administering water through the tubes. I honestly wouldn't have thought to do that, it's not taught either. Thanks for that.
The abdominal distention was relieved, however the diarrhea was almost constantly flowing throughout my shift. He did have a foley in place, but that was probably due to his immobility. Speaking of which, this patient was bedridden, and after doing some research I believe he had what is called decorticate posturing. We had to pry his arms away from his body to assess him. He would move his limbs sometimes when asked but it took him a while to do so and was not consistent.
The nurse for this patient told me that the ulcer was unstageable. I asked her why and she told me it was due to some yellowing tissue at the base of the sore. I did not understand that.
The symptoms for dementia, other than not speaking, were unassessable (if that's possible). How do you assess memory deficit or impaired thinking if the patient won't speak? I think this is where most of the confusion is coming from on my end. Towards the end of my shift he was making incomprehensible sounds, when asked if he needed something he would just stare at me. He had a flat affect the entire time. I don't know how his needs are met, it seemed as though the nurse only came in when she was scheduled to give meds.
The way I got these diagnoses was from my nursing diagnosis handbook. Those diagnoses were listed under dementia. "Impaired Verbal Communication" isn't in there, but that is basically what I was trying to get at. FTT was also in his chart; it didn't make sense to me (which started the cycle of confusion), but I thought that if it was in the chart I should have it on my concept map.
Thank you again for your post, I really do appreciate it a lot.
First, Just want to say thank you for the teaching on care plans. I've learned more from these threads than in the couple of class I've had at school.
Still, I seem to be confused and if you've already addressed this, please send me to the correct post.
pt. is 76 yo hx of dementia found unresponsive at home
pulse ox in the ambulance 72% improved after 02 admin to92%
Cxr in the ER showed Rll infiltrate consistent with pneumonia
UA=UTI
Admitting diagnosis is Mental Status Change, Pneumonia, UTI, Early sepsis.
My question is: Whats the priority diagnosis? I think hypoxemia r/t pnuemonia caused the mental status change. but older adults also suffer mental status changes from UTIs. What should my care plan focus on? I read where you said to focus on the signs and symptoms presented. I took care of this patient on her 5th hospital day and 02 sat was 100% on room air. She was confused at times, but has a hx of dementia. her foley was draining light yellow urine and her priority problem on the day I took care of her was nurtrition - poor appetite and weight loss since admission. As a student are you supposed to do the careplan based on the admitting dx or on the priority for the day? My careplan format specifically asks for the admitting dx.
Specializes in med/surg, telemetry, IV therapy, mgmt.
daytonite,
first, just want to say thank you for the teaching on care plans. i've learned more from these threads than in the couple of class i've had at school.
still, i seem to be confused and if you've already addressed this, please send me to the correct post.
pt. is 76 yo hx of dementia found unresponsive at home
pulse ox in the ambulance 72% improved after 02 admin to92%
cxr in the er showed rll infiltrate consistent with pneumonia
ua=uti
admitting diagnosis is mental status change, pneumonia, uti, early sepsis.
my question is: whats the priority diagnosis? i think hypoxemia r/t pnuemonia caused the mental status change. but older adults also suffer mental status changes from utis. what should my care plan focus on? i read where you said to focus on the signs and symptoms presented. i took care of this patient on her 5th hospital day and 02 sat was 100% on room air. she was confused at times, but has a hx of dementia. her foley was draining light yellow urine and her priority problem on the day i took care of her was nurtrition - poor appetite and weight loss since admission. as a student are you supposed to do the careplan based on the admitting dx or on the priority for the day? my careplan format specifically asks for the admitting dx.
as a student are you supposed to do the careplan based on the admitting dx or on the priority for the day?
this is a question you need to ask your instructors.
my careplan format specifically asks for the admitting dx.
you stated in your post: admitting diagnosis is mental status change, pneumonia, uti, early sepsis. that's what i would put on the form.
whats the priority diagnosis? i think hypoxemia r/t pnuemonia caused the mental status change.
hypoxemia
is not an official nanda nursing diagnosis.
pnuemonia
is a medical diagnosis and medical diagnoses are not permitted to be used as direct related factors in nursing diagnostic statements. if hypoxemia is the cause of mental status changes, aren't
mental status changes
the real nursing problem? is hypoxia their cause, or her underlying dementia? did you assess her lung sounds to get evidence of hypoxia? based on the information you supplied, the priority diagnosis i came up with was
imbalanced nutrition: less than body requirements r/t ??? aeb poor appetite and weight loss since admission
and i do not know the etiology because there just wasn't enough information. it could be because of her illness, her medications, or her dementia. i don't know. you worked with this patient and saw the information in her chart. i didn't. if i were your instructor i would question a priority nursing diagnosis of
imbalanced nutrition: less than body requirements
in a patient admitted with mental status changes, pneumonia, uti, and early sepsis. it sounds like something is missing.
a care plan is based on the nursing problems that the patient has. these are determined by applying the nursing process which is the problem solving tool that we use to do this.
step 1 assessment
- assessment consists of:
a health history (review of systems) - we know she is 76 years old, has a history of dementia, was found unresponsive at home
performing a physical exam - there isn't any physical exam information. for a patient with pneumonia i expected to find information about lung sounds, pulse ox and whether or not there is productive coughing and the color of any sputum. it takes weeks for pneumonia to heal, especially in the elderly. there is also no reference to vital signs. sepsis is
always
secondary to a primary infection and she has two of those (a uti and pneumonia). the symptoms of sepsis are:
temperature > 38° c or
heart rate > 90 beats/min
respiratory rate > 20 breaths/min or paco2
wbc count > 12,000 cells/μl or 10% immature form
you mentioned that she was confused, but didn't describe the confusion. confusion can be disorientation to person, place and time, misperceptions, hallucinations and patients can be agitated. since weight loss was brought up, during examination the patient should have been weighed and none of those figures are mentioned.
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - what can and can't she do? what does she need assistance with?
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need to look up and read about each of her medical conditions: pneumonia, uti, sepsis and dementia. you need to make sure that you didn't miss seeing any of the signs or symptoms of any of these conditions in her. this is how you will improve your assessment skills as well as learn about these diseases. i suspect she still has symptoms of her pneumonia but you missed seeing them. i'll bet she's still being treated medically for it, or am i wrong? does she need assistance with deep breathing and coughing? where would you fit that into a care plan?
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - no medications were mentioned. patient does have a foley and there can be complications with a foley catheter.
step #2 determination of the patient's problem(s)/nursing diagnosis part 1
- make a list of the abnormal assessment data
poor appetite and weight loss since admission
confused at times
step #2 determination of the patient's problem(s)/nursing diagnosis part 2
- match your abnormal assessment data to likely nursing diagnoses - based on the information you posted and sequenced by maslow's hierarchy of needs. . .
imbalanced nutrition: less than body requirements r/t ??? aeb poor appetite and weight loss since admission
[needs better description]
(acute or chronic) confusion r/t dementia aeb confused at times
"You need to make sure that you didn't miss seeing any of the signs or symptoms of any of these conditions in her. This is how you will improve your assessment skills as well as learn about these diseases. I suspect she still has symptoms of her pneumonia but you missed seeing them. "
I think this is the key. I have more detailed info on this pt. I was just looking for guidance on where to begin. i think I really wanted to focus on nutrition and was trying to justify it. You've set me on the right track, so thank you.
Specializes in med/surg, telemetry, IV therapy, mgmt.
1ldowife. . .as i said, if i were your instructor i would question a priority nursing diagnosis of imbalanced nutrition: less than body requirements in a patient admitted with mental status changes, pneumonia, uti, and early sepsis. it sounds like something is has been overlooked.
Desperately needing help...pt with +1 pitting edema, post-surg from an abdominal mass, 84yo, A&O x2, hadn't missed church in 37 years, NPO, on D1/2W NS with K, lives alone.... any help, would be appreciated...I have excess fluid volume (but really don't know what the related to would be)...also have spiritual distress,
my problem is my instructor thinks Im using ND's that are "a given" (ie-risk for infection, risk for falls, impaired mobility)
Specializes in med/surg, telemetry, IV therapy, mgmt.
desperately needing help...pt with +1 pitting edema, post-surg from an abdominal mass, 84yo, a&o x2, hadn't missed church in 37 years, npo, on d1/2w ns with k, lives alone.... any help, would be appreciated...i have excess fluid volume (but really don't know what the related to would be)...also have spiritual distress,
my problem is my instructor thinks im using nd's that are "a given" (ie-risk for infection, risk for falls, impaired mobility)
thanks in advance for any help! :)
certain nd's are "a given" for postoperative patients that have undergone general anesthesia. however, diagnosing follows a consistent process of first assessing the patient and then assembling the abnormal data you find from your assessment activity and using it to determine what the nursing problems are and establishing what labels go with them (nursing diagnoses). i will include these "given" nursing problems while going through how you should be incorporating looking for them in your assessment of this patient.
assessment is quite involved and consists of:
a health history (review of systems) - this you would have done by asking questions of the patient and reviewing information in the chart. historical information that you have posted about the patient here are that they are 84 years old, is post-surgical from an abdominal mass, lives alone, and hasn't missed church in 37 years. my first question when i read this information was if the mass was cancerous? second was what was the significance of mentioning that the patient had not missed church in 37 years? is that important to healing from an incision in the abdomen?
performing a physical exam - a big part of the reason we perform physical examinations is to check for abnormalities. the only physical exam data that was posted was that the patient had +1 pitting edema and was a&o x2. where was this pitting edema? which element was the patient not oriented to: person, place or time? since the patient had major surgery (removal of an abdominal mass) what does the incision look like? where is your abdominal assessment? patients get paralytic ileus following major abdominal surgery (this is an expected complication) so they must be constantly assessed for the return of intestinal activity--where is your assessment of that? npo is not an assessment, but a medical treatment. anyone undergoing general anesthesia must be monitored for the signs and symptoms of these potential complications:
any number of problems with the incision/wound (dehiscence, evisceration, infection)
fluid and electrolyte imbalances
urinary retention
constipation
surgical pain
nausea/vomiting (paralytic ileus
none of those assessments have been included in your post. post op patients at the least should be doing deep breathing exercises every couple of hours as well as being repositioned to keep circulation stimulated. when the patient goes into surgery, they have already been at least 8 hours without fluid. with their abdominal tissues open to the atmosphere more fluids are lost through invisible means. this creates a situation of electrolyte imbalance because electrolytes do not evaporate into the air along with water that is lost.
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - with an abdominal incision that probably hurts, is this patient jumping in and out of bed by themself to go to the bathroom? are they even getting out of bed? if this person were at their home right this moment, could they do what needed to be done for themself, or do they need the help of another person?
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this is important to the development of the "related to" parts of your nursing diagnostic statements because by knowing what the pathophysiology of the patient's medical condition is will lead to the cause of many of the problems. i must go back to one of my first questions. . .was this abdominal mass cancerous? why was this surgery done in the first place? what does the doctor say is going on in this patient's abdomen that warranted taking this person to the or and opening them up? that is extremely important information to know. we need to know what the doctor is thinking and what his medical plan of care is as well. what other medical problems does this patient have? at 84 years old i can't believe that there isn't some other medical disease or condition going on. they all need to be considered. and, you need to look each one of them up, read about its pathophysiology, its signs and symptoms and any complications they may pose to a person. why? because you may have missed seeing these signs and symptoms in the patient. this is how you will learn to improve your assessment skill as well as learn about these specific diseases and conditions. edema occurs for many different reasons, not just because of excess fluid in the system. why is it happening to this patient? see http://www.medicinenet.com/edema/article.htm to learn about edema. after considering all the patient's known medical conditions and medications the explanation for the edema should be clearer.
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - i know this patient is probably on something for pain. ??? what other medications is the patient getting and why? what are their side effects? being npo is a treatment that has been ordered by the doctor. why? see http://www.merck.com/mmpe/sec02/ch011/ch011g.html (paralytic ileus; adynamic ileus; paresis). d1/2w ns with k is another treatment ordered by the doctor. why? can we survive without fluid? what electrolytes need to be continuously replaced in our bodies? see table of commonly used iv solutions.doc. are any dressing changes being done?
assemble abnormal data: all you provided is. . .
+1 pitting edema - not enough information to determine why the edema is present
a&o x2
determine nursing problems from the assessment and abnormal data:
acute confusion r/t effects of anesthesia and age aeb disorientation to (person, place or time).
--------------------------------------------
the nursing diagnoses you propose. . .
excess fluid volume
not likely since this is a postop situation. at 84 years old i was looking for possible heart failure to explain the patient's edema, which i assumed was in the lower extremities, or immobility. edema in the lower extremities is often the result of a circulation problem.
spiritual distress
this may be, but this is a postop patient that just had their abdomen cut open. i don't think your instructor is going to be impressed that this is one of the only problems that you found. what about keeping the lungs clear, getting this person mobile again, incisional pain, keeping the abdominal wound clean and assisting it to heal? after all, that is why the patient is there for our
nursing
help.
-------------------------------------
now, this thread from 2 years ago is also about a postoperative patient's care plan although it is a different type of surgery. however, the givens are pretty much the same. i did give 3 diagnoses from the information the op presented. have a look at these given nursing problems.
I know what you mean about they shouldn't be overjoyed about the spiritual thing, but for some reason our instructors want their 'happiness' to be up there on the list of priorities because if they are stressed or unhappy then the body may 'resist' healing or something to that effect. I, personally think acute pain trumps all else, but they are "tired" of seeing that as a ND. I guess more than anything, I'm having trouble reading minds :chuckle
I will put your list and advise to good use though, thank you so much.
Side note- I don't know if you get paid to do what you do, but I think allnurses.com should hold a bake sale or something to raise money to give to you as a thank you for how much you do on this site and how many people you help....until then, my gratitude is what I can offer!...so THANK YOU!
jen39452
3 Posts
Hi, I need some help with a nursing care plan. I was in clinicals and was assigned to a patient with a sigmoid colectomy with partieal cystectomy. This patient has a past history of CAD, Diverticulitis, HTN, IDDM, and VAG abscess. I need at least 4 diagnosis. Plus I need some labs on this patient. I have some lab results but I didn't have time to get them all. I really do need some help on this one. Thanks!!!!