Help with my first Care Plan

Published

patient info

in december 2008 the pt had gone outside his house to brush the snow off his car and was very sob. he lost consciousness, turned purple and when ems arrived the pt was found to be not breathing and needed bag mask ventilation. he was inubated in the emergency room and remained on the ventilator for 24 hours. during hospitalization the pt was made comfort care. the pt has episodes of confusion and delirium. pt is now in a long-term care facility.

diagnoses

primary - respiratory failure.

secondary ones -other specific organic brain syndromes (chronic).

unspecific disorder of kidney & ureter.

atrial fibrilation.

other unspecific sleep apnea.

irregular results of cbc

urea nitrogen 38 *high

creatinin 1.75 *high

wbc count 13.2 *high

hemogloblin 13 *low

hematocrit 40.9 *low

rbc count 4.41 *low

vitals

bp - 129/75, temp - 96, p - 82, resp - 24.

other information

religion protestant, previous occupation - salesman.

i need like 2 nursing diagnoses with supporting data, key assessments, reason for healthcare, outcome objective (patient will...), nursing interventions with a rationale... like i said this is my first nursing care plan just looking for some guidance/help. :) thank you in advance

~leaf

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

you can see examples of how care plans are developed on this sticky thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

you haven't posted enough information for me to help you very much except get you started. a care plan is about determining the patient's nursing problems and strategies to do something for them. we use the nursing process, which is a problem solving tool, to help us. it consists of 5 steps and if you look at the posts on the thread listed above you will see example after example where i demonstrate the use of the nursing process. all care planning begins with step #1 of the nursing process which is assessment. it is an involved step from which we are looking for abnormal data to fall out which will become the signs and symptoms of the nursing diagnoses (nursing problems) we choose in step #2 of the nursing process which is problem determination. assessment consists of:

  • a health history (review of systems) - religion protestant, previous occupation - salesman. in december 2008 the pt had gone outside his house to brush the snow off his car and was very sob. he lost consciousness, turned purple and when ems arrived the pt was found to be not breathing and needed bag mask ventilation. he was intubated in the emergency room and remained on the ventilator for 24 hours. during hospitalization the pt was made comfort care. he is now in a long-term care facility. he has episodes of confusion and delirium.
  • performing a physical exam - where is your physical exam data? lung sounds? abdominal assessment? does he have any edema? since he has confusion is he oriented? can he talk? follow instructions? does he walk? is he bedridden? how is his skin? any bedsores? is he incontinent, or does he have a foley catheter?
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - how does he get bathed? dressed? get in and out of bed? eat? does he need help with these activities and how much help?
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - the patient has respiratory failure, sleep apnea, atrial fibrillation, chronic organic brain syndrome (organic brain syndrome is a general term referring to many acute and chronic physical disorders that cause impaired mental function with alzheimer's disease being the most common. symptoms include confusion, impaired memory, judgment, and intellectual function, and agitation - did the patient have any of these symptoms?), an unspecified disorder of the kidney and ureter. you need to look up each of these medical problems so that you learn about their pathophysiology and signs and symptoms. the pathophysiology is needed to determine the cause (related factors) for any nursing diagnoses you finally use. and, you need to know the signs and symptoms of these diseases to make sure you didn't miss seeing any of them when you assessed this patient. it will improve your assessment skill when you assess your next patient.

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - abnormal labs included urea nitrogen 38 *high, creatinine 1.75 *high, wbc count 13.2 *high, hemoglobin 13 *low, hematocrit 40.9 *low, rbc count 4.41 *low. you didn't list any of his medications and nothing about his diet.

since your post was primarily historical data and no assessment data, i cannot help in determining what this patient's current nursing problems are. follow the questions i've asked about the physical exam and adl assessments. look up information about the patient's medical diseases. i did look at the abnormal labs but they are not helpful without the physical assessment information to go along with them.

PEBBLES1

284 Posts

Specializes in heart failure and prison.

Did your school give you a nursing dx book. If so check their or you should have a fundamentals book they have care plans and outcomes in those books

LeaF35

2 Posts

"you haven't posted enough information for me to help you very much except get you started." daytonite this was all the information i was given i have given you as much as i was actually given and i met this patient once where i was not able to perform a physical (no lung sounds, abdominal assessment, etc) but solely observe him for roughly 30 minutes...

from my observations he is not orientated, he can speak but only 3/4 makes sense and he does follow instructions moderately well... he is bedridden and does not walk, he does not have a folley the cnas bring him to the bathroom/change him. "does he get bathed? dressed? get in and out of bed? eat? does he need help with these activities and how much help?" he is fully dependant upon cnas for these activities he needs to be fed and helped with the rest.

"confusion, impaired memory, judgment, and intellectual function, and agitation" he had all of these symptoms as he thought he had a doctors appointment that day when he had gone the previous night and would get angitated when we kept telling him he didn't etc. he also keeps reaching out at the air because he had a cat and he thinks its on the floor in front of him which is where part of the delirium comes from. i was not able to see what type of condition his skin was in or if he had bedsores but i know he is sitting literally all day in a recliner chair as he is basically confined to that, as his family does not want him going to the dinning room. so he has to eat in his room and he's in there literally all day in his recliner.

This topic is now closed to further replies.