Help! I need to simplify my care plan...

Daytonite, BSN, RN · Aug 11, 2009

you say "this gentleman has chf, and he has fallen 4 times within the last 2 weeks and has multiple cuts and bruises all over his body. he also has a colostomy. and a million other things wrong with him, but those are the ones i focused on..." that's chf, falls and a colostomy. i begin to read your first nursing diagnosis and i see this:

fluid volume overload r/t

decreased glomerular filtration

secondary to decreased cardiac output and pulmonary congestion aeb decreased urine output, elevated b/p, advantageous breath sounds (crackles, wheezing), 5lb weight gain within 24 hr period, dyspnea, jugular vein distention and peripheral edema

that's kidney disease. that's not chf. later in the post i read he has renal insufficiency.

so, i go down and look at your second diagnosis:

impaired skin integrity r/t trauma,

permanent surgical opening on skin surface

(colostomy stoma)

impaired circulation

,

limited mobility

and fragile tissues aeb multiple skin tears, lacerations and areas of ecchymosis on body.

that's not falls. now, you've introduced a skin problem, physical mobility and impaired circulation is a medical problem.

i get the "million other things wrong with him", but when your instructors tell you to simplify and narrow things down that doesn't mean you have to figure out a way to include all the guys problems into two diagnoses. you'll eventually have to prioritize everything and just pick the top two problems and focus on them.

fluid volume overload r/t decreased glomerular filtration secondary to decreased cardiac output and pulmonary congestion aeb decreased urine output, elevated b/p, advantageous breath sounds (crackles, wheezing), 5lb weight gain within 24 hr period, dyspnea, jugular vein distention and peripheral edema

fluid volume overload
is not an official nanda diagnosis. i double checked my copy of
nanda international nursing diagnoses: definitions and classifications 2009-2011
and it isn't in there.
you probably want to use
excess fluid volume
however
. . .
decreased cardiac output
is a nursing diagnosis that would take priority over
excess fluid volume
and it is inappropriate to use it as an etiology of this fluid retention problem. so what you really have here is two nursing problems:
1. decreased cardiac output
2. excess fluid volume r/t impaired excretion of sodium and water aeb decreased urine output, elevated b/p, pulmonary congestion, advantageous breath sounds (crackles, wheezing), 5lb weight gain within 24 hr period, dyspnea, jugular vein distention and peripheral edema
[*]
pulmonary congestion
is actually a defining characteristic (symptom) of
excess fluid volume
and so it doesn't belong in the diagnostic statement as a related factor.

impaired skin integrity r/t trauma, permanent surgical opening on skin surface (colostomy stoma) impaired circulation, limited mobility and fragile tissues aeb multiple skin tears, lacerations and areas of ecchymosis on body.

there is
impaired skin integrity
and
impaired tissue integrity
.
impaired skin integrity
is only the epidermis and/or dermis.
impaired tissue integrity
is used for everything else that goes any deeper. therefore, wounds have to be measured and described. that includes assessing their depth, even the skin tears and lacerations. with lacerations you need to know if the cut went into the subcutaneous layers of the skin. if they did, then the correct diagnosis for those is
impaired tissue integrity.
if falling is the cause (etiology), then one diagnosis that can be used is
risk for falls r/t history of falling, impaired circulation and limited mobility.
a colostomy is only an
impaired skin integrity
problem when the bowel contents are getting on the patient's skin, causing irritation and the skin is getting reddened and/or breaking down. if that isn't happening then you can't list it as a etiology.
if the patient has
limited mobility
then they should be diagnosed with
impaired physical mobility
. it makes no sense that limited movement would be the cause of skin breakdown. i think you meant immobilization.
i wouldn't use
fragile tissues
. it has no scientific basis and sounds unprofessional.

- - - - - - - - - - - - - -

i really think decreased cardiac output should be your #1 diagnosis if this patient has chf. the excess fluid volume should be your #2 diagnosis.

- - - - - - - - - - - - - -

nanda #1:

fluid volume overload r/t decreased glomerular filtration secondary to decreased cardiac output and pulmonary congestion aeb decreased urine output, elevated b/p, advantageous breath sounds (crackles, wheezing), 5lb weight gain within 24 hr period, dyspnea, jugular vein distention and peripheral edema

goal:

patient will demonstrate stabilized fluid volume by balanced input and output, breath sounds clear/clearing, vital signs within acceptable range, stablized weight and absence of edema

here's your problems with this as a goal statement
- the patient has to have a desired response "demonstrate stabilized fluid volume". as i read that i said to myself, "what is stabilized fluid volume?" then i see you are going to describe it--or are you?
- goals need to be measurable: how much, how long, how far or on what scale you are using. is this man going to have a balanced input and output if he gets diuretics? his output is going to be greater than in input and it won't be balanced. what's an "acceptable" range for vital signs for this man? state them. is his weight going to be stabilized if he is getting diuretics? it's going to change, isn't it? what was his weight anyway? how are you going to know when his edema is gone? were circumferencial measurements taken of his legs?
- when and how long will it be that we are going to see these goals attained?

intervention 1: record accurate i&o and calculate 24 hr fluid balance.weigh daily.

remember your instructor said simplify. this is actually 2 interventions.

record accurate i & o and calculate 24 hour fluid balances.
- why wouldn't i & o be done accurately? i wouldn't even put that word in there. this is the way i would write this: record 24 hour i & o.

[*]weigh daily.

rationale: will determine actual degree of fluid retention and identify whether excessive fluid intake is a contributing factor.

assessment helps establish baseline data that will help the nurse identify if fluid intake or a physiologic problem is the source of the fluid retention.

intervention 2: consult with dietician to see if patient should be placed on low sodium diet and/or fluid restrictions.

again, no mention of the diet in your goal. the diet and fluid restrictions would be a short term goal and the resolution of any edema or congestion would be more of a longer term goal.

rationale: sodium retains water and increases fluid retention, especially in a pt. with renal insufficiency. water and other fluids increase overall fluid volume which in turn elevates blood pressure and adds to pulmonary congestion.

decreased renal flow results increases in aldosterone and antidiuretic hormone secretion, water and sodium retention as well as potassium excretion which contributes to edema formation and pulmonary congestion.

intervention 3: have patient remain in semi-fowlers position in wheelchair or during bed rest and have feet elevated while sitting. change positions frequently and assist with ambulation and rom as tolerated.

this is treating the patient's dyspnea! yet your goal (goals also predict what will happen as a result of your nursing interventions) never mentions anything about the patient having ease of breathing! you need to correct that if you keep this intervention.
simplify. you've actually got multiple interventions here:
- place in semi-fowler's position with feet elevated
- change position frequently (i would put this with impaired skin/tissue integrity)
- assist with ambulation (i wouldn't include this and don't see the need for it)
- assist with rom (i wouldn't include this and don't see the need for it)

rationale: semi-fowlers positioning will facilitate diaphragm movement and improve respiratory effort. elevating legs will reduce stasis of fluid in lower extremities. position changes and moderate physical activity will improve overall circulation and reduce stasis of fluids, risk for tissue injury, and risk for thromboembolism.

putting the patient in a semi-fowler's position shifts the abdominal organs downward and away from the lungs giving them more room to expand and do their work. it also promotes diaphragmatic breathing. breathing from the diaphragm helps to reduce the respiratory rate and increase the air going into the alveoli upon inspiration. by increasing the amount of air going into the alveoli with normal respirations you will be promoting the dislodgment and expulsion of mucous that might be trapped there.
i would list this intervention first. why? respiratory needs come before others (fluids and diet).

how i would care plan this:

excess fluid volume r/t

impaired excretion of sodium and water aeb dyspnea, crackles, wheezing, jugular vein distention, peripheral edema, 5lb weight gain within 24 hr period, decreased urine output, and elevated b/p.

goal: in 3 days patient will breath will be regular and unlabored, all lung fields will be clear to auscultation.

intervention 1:

position in semi-fowler's position with feet elevated

rationale:

putting the patient in a semi-fowler's position shifts the abdominal organs downward and away from the lungs giving them more room to expand and do their work. it also promotes diaphragmatic breathing. breathing from the diaphragm helps to reduce the respiratory rate and increase the air going into the alveoli upon inspiration. by increasing the amount of air going into the alveoli with normal respirations you will be promoting the dislodgment and expulsion of mucous that might be trapped there.

intervention 2: record 24 hour i & o.

rationale:

assessment helps establish baseline data that will help the nurse identify if fluid intake or a physiologic problem is the source of the fluid retention.

intervention 3: consult dietitian regarding low sodium diet and fluid restriction.

rationale:

decreased renal flow results in increases of aldosterone and antidiuretic hormone secretion, water and sodium retention as well as potassium excretion which contributes to edema formation and pulmonary congestion.

- - - - - - - - - - - - - -

nanda #2

impaired skin integrity r/t trauma, permanent surgical opening on skin surface (colostomy stoma) impaired circulation, limited mobility and fragile tissues aeb multiple skin tears, lacerations and areas of ecchymosis on body.

impaired skin integrity r/t trauma aeb [location and description of all wounds]

goal: patient will regain integrity of skin surface by demonstrating timely and complete healing of all wounds and sustain no infection or further injury to epidermis

using the word timely is inappropriate. you have to state when something is supposed to happen. healing of skin and tissue and the process of exactly how it happens is well-known and you can research and find this information. the problem is that i am not sure that there was adequate assessment of these "wounds" and that they have been appropriately diagnosed.
complete healing would be a long term goal. and is it fair to include all wounds in this?
sustaining no infection or further injury to epidermis can be a goal, but it is one of many. you are supposed to keep this simple.

intervention 1:

assess entire skin surface noting color, turgor, temperature and sensation. carefully assess all wounds and record information including: anatomical location of wound, size, depth, amount and characteristics of drainage, condition of wound bed, presence and depth of sinus passages or tunneling, presence of granulation tissue or slough/eschar. check wound edges and skin around wound for erythmia. document all findings.

i really would like to know what "all wounds" these are. i still have no idea if you are talking about boo-boos on the coccyx, toes, the back of his head or his knee. where are these wounds? it's pretty silly to say record information when no one knows what you are talking about. draw a picture if you have to. i drew simple pictures on care plans all the time. you never know who is going to be reading your care plan. anyone reading your care plan should get a clear "picture" of what the patient's problem is after reading about it and not have a lot more questions.

rationale:will provide a comparative baseline for future assessments to establish progression towards goal.

intervention 2:

change dressings as indicated by physicians order to facilitate healing and prevent infection. maintain asepsis during dressing changes and ensure that dressings are secured properly.

rationale: aseptic technique reduces the entry of pathogens into the wounds

change dressing if it becomes wet or saturated with drainage.

rationale: contact of the normal skin with drainage from the wound can cause skin maceration and breakdown.

have each nurse who performs dressing change document time, date, and initials on dressing, and document assessment findings in chart.

rationale: documentation establishes an objective record of any progress made that can be attributed to the nursing interventions.

monitor for signs of infection such as purulent discharge, erythmea, or foul odor.

monitor for these signs of local wound infection: purulent drainage and erythema.
monitor for these signs of septicemia: temperature > 38° c or 90 beats/min, respiratory rate > 20 breaths/min or paco2 12,000 cells/μl or 10% immature form

rationale: regular skin inspection enables early detection of damage and infection. infected wounds will require more of both medical and nursing interventions.

monitor lab values for increased wbc count.

these are multiple interventions.
to facilitate healing and prevent infection is the rationale for changing the dressings.
signs of infection are a purulent discharge with a foul odor

rationale: will ensure that dressings are being changed on schedule (no) and will allow early intervention in case of infection.

intervention 3: (delete all--they do not apply)

ensure that patient always has his bed in lowest position with side rails up, bed alarm in working order and call bell within reach. when in wheelchair, ensure that seat and tab alarm are in working order.

has nothing to do with

impaired skin integrity

and wounds of the skin. this is an intervention for

risk for falls

.

check on pt. q15 min and do not leave him in room unsupervised unless sleeping.

has nothing to do with

impaired skin integrity

and wounds of the skin. this is an intervention for

risk for falls

.

if pt. is on bedrest, turn and reposition q2h and check for any signs of potential skin breakdown. cleanse and massage areas over bony prominences with protective ointment prn.

cleanse areas of intact skin with mild soap and water and pat dry. apply lotion to dry skin

this is all

risk for impaired skin integrity

. has nothing to do with impaired skin.

change ostomy pouch when it becomes 1/3 full and ostomy appliance weekly or prn when leaking. carefully remove adhesive backing by holding skin taut and pulling back slowly. apply skin prep before attaching new appliance and hold skin taut when applying to prevent wrinkles. cleanse peristomal area with soap and water and pat dry.

unless the skin around the stoma is reddened, these interventions do not belong here.

encourage pt. to ask for assistance when he needs to urinate, and to alert staff if he has been incontinent so that his brief can be changed.

if this patient is incontinent then address that under a diagnosis for incontinent or one of the toileting self-care deficit, not here.

during 2 hour check ensure that all dressings are secure and intact and that pt. is wearing his geri-gloves.

to shorten things up on the care plan, you can leave this intervention out.

ensure that pt. is receiving adequate nutrition including high amount of calories, protein, vitamin a, c, and zinc.

rationale: will prevent further injury/skin breakdown and facilitate healing

adequate nutrition, protein and proper vitamins

does not

prevent further injury and skin breakdown! if it did people would be gobbling them up and there were would all kinds of supermen and women walking around.

MattiesMama · Aug 12, 2009

Thanks for taking the time to do all that Dayonite...much appreciated as usual!

I'm still working on the CHF care plan but here is my revised (and much simplified!) Impaired skin integrity care plan:

Impaired skin integrity r/t trauma AEB 2.6x8.8cm Skin tear on left upper forearm with partial thickness skin loss, 7.9x4.5cm laceration on posterior aspect of elbow with partial-thickness skin loss, and 1.5x1.5cm skin tear on left calf with partial thickness skin loss.

Goal: By the end of 3 weeks, all current wounds will reach the proliferation stage of healing AEB contraction of wound edges, epitheliazation, presence of granulation tissue and no signs of systemic or localized infection,

Intervention 1: Carefully assess all wounds and record findings in wound care flow sheet using objective information in the format used by SCC (

Rationale: Will provide a comparative baseline for future assessments to establish progression towards goal. Using a standardized format for documentation will allow clinical staff to communicate wound assessment from the same frame of reference and avoid using subjective descriptions in documentation

Intervention 2: Change dressings as indicated by physicians order while maintaining aseptic technique

Rationale: Dressings must be changed on schedule and in the prescribed manner to facilitate healing and reduce chance of infection. Aseptic technique reduces the entry of pathogens into the wounds.

Intervention 3: Monitor for signs of infection as follows:

Local wound infection: purulent drainage and presence of erythema.

Systemic infection/septicemia: Temperature > 38° C or 90 beats/min, Respiratory rate > 20 breaths/min or Paco2 12,000 cells/μL or 10% immature form

Rationale: Regular skin inspection and assesment enables early detection of damage and infection. Infected wounds will require more of both medical and nursing interventions.

WDYT?

Daytonite, BSN, RN · Aug 12, 2009

the interventions and rationales are all fine. most that i would critique would be how they are worded. i tend to focus on wording things toward a positive slant keeping away from as much negative reference as possible. the only negativity, i feel, belongs to the original assessment data that is the evidence of the problem. from there everything progresses toward improvement as much as possible. i would get a copy of the scc wound care flow sheet and attach it to your care plan. it will help explain some of the documentation you are referring to. check the spelling on some of your words. i've already corrected some of them. i think "epitheliazation" is spelled wrong, but my taber's is buried at the moment and i can't get to it.

impaired skin integrity r/t trauma aeb 2.6x8.8cm skin tear on left upper forearm with partial thickness skin loss, 7.9x4.5cm laceration on posterior aspect of elbow with partial-thickness skin loss, and 1.5x1.5cm skin tear on left calf with partial thickness skin loss.

i would be a little hesitant to use the term "

partial thickness skin loss

" unless you clear it with your instructor because it is a diagnostic term. so is "

laceration

". use generic wording. all you are doing in the aeb section is repeating the nursing diagnostic term. everything in the aeb section has to be a presentation of the evidence of the problem,

impaired skin integrity

. we already know it has to be broken skin of some kind. now you have to describe length, width and height, location and any drainage. if you don't have the depth of these wounds don't muck it up by using terms like

partial-thickness skin loss

. do they have drainage or dried scabs on them? you can use descriptions like that.

ex:

aeb open wounds without drainage on outer aspect of middle of left upper forearm measuring 2.6 x 8.8cm x __ mm deep, outer posterior aspect of elbow measuring 7.9 cm x 4.5cm x __ mm deep and posterior lower third of left calf measuring 1.5 cm x 1.5 cm x __ mm deep.

goal: by the end of 3 weeks, all current wounds will reach the proliferation stage of healing aeb contraction of wound edges, epitheliazation, presence of granulation tissue and no signs of systemic or localized infection.

my only suggestions would be with the wording. . .ex:

goal: at the end of 3 weeks, wounds will have advanced to the proliferation stage of healing aeb contraction of wound edges, epitheliazation, presence of granulation tissue with no signs or symptoms of systemic or localized infection.

intervention 1: carefully assess all wounds and record findings in wound care flow sheet using objective information in the format used by scc (

my only suggestions would be with the wording. . .ex:

assess all wounds with each am dressing change and record findings on wound care flow sheet used by scc.

state when an assessment is to be done and documented. once every 24 hours is acceptable. otherwise there will be confusion as to when this assessment is to be done and it will not get done at all.
the word "
carefully
" is unimportant and adds nothing to the intervention. we know we are supposed to be "
careful
".
documentation is an active verb and is physically done "on" a physical sheet of paper, not "in" it.
i would delete the words "
using objective information in the format
" since the people who document the information on these sheets should already know this coding. saying this is redundant and only takes up extra space on your care plan. i'm trying to remember that your instructor wants you to simplify here.

rationale: will provide a comparative baseline for future assessments to establish progression towards goal. using a standardized format for documentation will allow clinical staff to communicate wound assessment from the same frame of reference and avoid using subjective descriptions in documentation

just shortening to more concise wording:

providing an assessment establishes if progression is being made toward goals. using standard documentation discourages the use of subjective descriptions and allows staff to communicate objective wound assessments using the same frame of reference.

note: the
baseline assessment
was done when the diagnosis,
impaired skin integrity
was determined.

intervention 2: change dressings as indicated by physicians order while maintaining aseptic technique

my only suggestions would be with the wording. . .ex:

perform aseptic dressing changes ___ (this is per physicians order)

on a care plan, like a medication sheet, the specific times or time intervals should be stated even if it was ordered by the doctor. if you don't state it there will be confusion and it won't get done. if aseptic style is ok that should be indicated as well. these are nursing orders.

rationale: dressings must be changed on schedule and in the prescribed manner to facilitate healing and reduce chance of infection. aseptic technique reduces the entry of pathogens into the wounds.

intervention 3: monitor for signs of infection as follows:

local wound infection: purulent drainage and presence of erythema.

systemic infection/septicemia: temperature > 38° c or 90 beats/min, respiratory rate > 20 breaths/min or paco2 12,000 cells/μl or 10% immature form

my only suggestions is with your formatting. make sure these s&s can be seen very easily. . .ex:

monitor for signs of local and systemic infection as follows:

local wound infection:
- purulent drainage
- presence of erythema.
[*]
systemic infection/septicemia:
- 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

rationale: regular skin inspection and assessment enables early detection of damage and infection. infected wounds will require more of both medical and nursing interventions.

MattiesMama · Aug 14, 2009

Just wanted you to know I ended up getting an "A" on my care plan! More importantly I feel like I'm really starting to understand the whole process...thanks so much for your help!

Daytonite, BSN, RN · Aug 15, 2009

Shut up! Guess you didn't go overboard this time! I am proud of ya. Keep up the good work!

:dancgrp:

I was thinking after my last post to you that I should have given you some of the rules on writing nursing interventions, but it doesn't come up often so I never get to post them. Interventions are nursing orders for care, instructions. Write them so that anyone else reading them knows exactly what they need to do with the patient.

Use action verbs.
State when and how to perform the action.
Identify any special equipment or resources that need to be used in performing the action.
Be as short and concise as possible.