help with nursing dx and care plan

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I found this site last week and I love it! I've been telling my classmates about it. Okay, my client was a 16 yr old, para 1, grava 1, lacerations repair, history of chlamydia, intake 400 ml and output 800 ml per day of care (4 hours), scant lochia, vitals and labs wnl, 40 wk gestation. So far I've gotten acute pain, risk for infection, risk for deficient fluid volume, risk for constipation(?), risk for ineffective coping, deficient knowledge,and readiness for enhanced family coping. I have to have 10 dx and care plans for the top 5. I do pretty good with my interventions, but always get counted off for not having enough assessment data. Any advice will be greatly appreciated.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

care planning is based on determining what the patient's nursing problems are. this is done by using the nursing process which consists of 5 steps, the first of which is assessment. the entire care plan is based on everything that was discovered during assessment. that is the critical thinking or logic of care planning. this is why your instructors are counting you off for not having enough assessment data. nursing interventions are supposed to target the abnormal data that was discovered during the assessment process; that abnormal data is the evidence that supports the nursing diagnoses. all nursing diagnoses, like medical diagnoses, can be broken down into the patient's signs and symptoms to tell a story about the problem. your interventions are solutions to do something for each of those signs and symptoms because that is how you eat away at the problem in correcting it. doctors do the same thing in treating disease. the instructors can tell from the way your care plans are constructed that you are not utilizing the nursing process. i was out of town last week so i did not have a chance to answer your posts.

assessment consists of:

  • a health history (review of systems) - this is a 16-year old which makes this not only an ob care plan but it also has pediatric implications as well. this is a baby having a baby. the patient is an adolescent in erickson's stage of identity vs, role confusion where the child tries integrating many roles (child, sibling, student, athlete, worker) into a self-image under role model and peer pressure. this one is taking on the role of mother in a big way! there's a nursing problem right there. she has a history of chlamydia. i'm sure the story behind that is fascinating, but it should be addressed.
  • performing a physical exam - the only physical exam assessment is that there is scant lochia. lochia should be assessed for amount, character, odor, and how many pads are saturated. the fundus should be firm and midline. since she lacerated, she has sutures, so her perineal area should have been observed for evidence of inflammation and bruising. it is common for these mothers to have edema, redness, bruising and potentially drainage from these repaired lacerations. she may now have external hemorrhoids. did you check? pain needs to be measurable and is usually stated as a number on a scale of 0 to 10. breasts need to be checked for tenderness, redness, bruising and blistering. is she breastfeeding? there are 3 diagnoses to cover breastfeeding. dvt is a complication of the long hours of labor so the legs should be inspected frequently for signs and symptoms of dvt even a day or two after birth. did she talk about her labor experience? does she ask about how to care for the baby? how did she interact with the baby? the answers to these questions have to be put into written language and made a part of your written assessment and because you need the data as evidence to support nursing diagnoses.
  • 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/treatments that have been ordered they are taking

to care plan, begin by following the steps of the nursing process. . .

step 1 assessment

  • 16 yr old, para 1, grava 1

  • laceration repair

  • history of chlamydia

step #2 determination of the patient's problem(s)/nursing diagnosis part 1
- make a list of the abnormal assessment data

  • laceration assessment ???

  • intake 400 ml and output 800 ml per day of care

  • scant lochia

step #2 determination of the patient's problem(s)/nursing diagnosis part 2
- match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - this is limited because of the assessment data that was provided.

  • impaired tissue integrity r/t perineal laceration

  • risk for imbalanced fluid volume r/t inadequate fluid intake

  • risk for impaired parenting r/t young parental age, single parent who is a student, role strain and stress of tasks ahead
    .

other diagnoses that often get used are:

  • fatigue

  • anxiety

  • effective or ineffective breastfeeding

  • risk for caregiver role strain

step #3 planning
(write measurable goals/outcomes and nursing interventions

impaired tissue integrity r/t perineal laceration

  • goal:
    to promote comfort and healing of perineum

  • interventions:

    • take vital signs q4h

    • assess perineal area by having mother lie in a side lying position and flex upper leg forward and you lift the buttock, using a flashlight, looking for redness, ecchymosis, edema, discharge and approximation and number and size of any hemorrhoids.

    • perform perineal cleansing by placing patient on pan for this purpose, separating the labia, running warm water over the perineum from front to back and then patting dry from front to back

    • cleanse the perineum after each voiding and defecation

    • teach the patient how to do self perineal cleansing

    • notify the physician if there are any symptoms of infection

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Thank you so much!! You really pointed out several things I hadn't thought about. If you aren't an instructor, maybe you should be. :D I have read several of your posts and you make it easier to get a clear picture. Thanks for taking the time to help.

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I really think Daytonite should be an instructor as well. I have been reading her posts for about a year now. She has helped me a lot through nursing school. If not an instructor, she should at least write a book!

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i totally agree with blueh20!!! daytonite is awesome and has also helped me quite a bit...i would so love for her to be my mentor :lvan:

thank you daytonite

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Daytonite is awesome. I just signed up but prior to signing up I was using the information that he/she provided. They have helped me a lot with my careplans. They are always very thorough and provides information to point you in right direction. Thank you daytonite.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Daytonite is awesome. I just signed up but prior to signing up I was using the information that he/she provided. They have helped me a lot with my careplans. They are always very thorough and provides information to point you in right direction. Thank you daytonite.

Welcome to AN! The largest nursing community on the internet!

Sadly we lost Daytonite in 2010.....yet she remains an ever present force here on AN. There are several of us who cruise the student assistance forms helping students. Iam one ofthem....again welcome.

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i realize the op was a long time ago, but it bears repeating because someone else is reading it now: if an instructor is marking you down for lack of support for your diagnoses, you have to be clear about what parts of your assessment made you choose that diagnosis. you cannot say, my patient is "16 yr old, para 1, grava 1, lacerations repair, history of chlamydia, intake 400 ml and output 800 ml per day of care (4 hours), scant lochia, vitals and labs wnl, 40 wk gestation" (or any medical diagnosis), and pull a nursing dx out of, umm, the air from that.

you think she's constipated? safe guess, but what's your evidence for making that diagnosis? same for all the rest: acute pain (already postpartum? mmmmm, maybe not; convince me), risk for infection (why do you say that?), risk for deficient fluid volume (why?) , risk for ineffective coping (why-- did she say something to you about that?), deficient knowledge (of what, and why is it deficient?), and readiness for enhanced family coping. where is your evidence? your evidence, your assessment data that support these? that's what you have to figure out.

if you don't already have a nanda-i 2012-2014, get it now. this is the definitive, authoritative, be-all, mostly end-all book on nursing dx, and will assist you for the rest of your school and maybe the rest of your career (i use it on every case i do).

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