I need some help with my first (not actual patient) careplan.

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I have a 78 year old female patient (with history of IDDM) who had a medical diagnosis of DKA.

She is nauseous and has been vomiting. She is frequently urinating. Upon assessment I find her to find sunken eyes and a dry burrowed tongue. She has sinus tachycardia. chest xrays reveal infiltrates

Her respiratory rate is 36

Her BP is 92/54

Her pulse rate is 108 bpm

Well we need to have 3 actual diagnoses and I said

Temperature

Respiration

Dehydration

Vomiting/Nausea

I came to the conclusion that the dehydration must be first addressed... but I'm getting it confused ... Now Idk if the vomiting should be first... but then I think temperature must be addressed first... AHH lol.

Well my reasoning is that the temperature could be causing the high respiration, no? If there is a fever the metabolic activities speed up and well that includes breathing because we need oxygen and in this case more to keep up with the high metabolic rate. I figure that the fever could be caused by an infection and if that's so ... How do I(as the nurse) even address that I will fix it? I suppose cold packs? and hydration? HA!!! but then if I hydrate I have already knocked out dehydration .... ermm no?

I know the dehydration is caused by the hyperosmolar nature of the blood due to all the glucose outside her cells which cannot absorb the glucose due to the lack of insulin (IDDM)...

No, not askin' for someone to do this for me. As you can tell I'm very much into this case ... But I need some guidance and clearance.. please (=

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I'm hoping someone in critical care care will jump in for you, but I agree with your 1st judgment that dehydration may be addressed via IV fluid replacement as your 1st diagnosis or "deficient fluid volume". The fever may come down as fluids are replaced. The hyperglycemia, electrolyte imbalances, acid-base imbalances, and possible infections will have to be addressed. You will be closely monitoring labs, urine output, etc. with the goal that the patient will become and remain stable. Patient education on prevention could also be included in you care plan; there may be a "knowledge deficit"!

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I'm hoping someone in critical care care will jump in for you, but I agree with your 1st judgment that dehydration may be addressed via IV fluid replacement as your 1st diagnosis or "deficient fluid volume". The fever may come down as fluids are replaced. The hyperglycemia, electrolyte imbalances, acid-base imbalances, and possible infections will have to be addressed. You will be closely monitoring labs, urine output, etc. with the goal that the patient will become and remain stable. Patient education on prevention could also be included in you care plan; there may be a "knowledge deficit"!

well of course someone would need to jump in..... I'm a first semester nursing student. This is my first care plan and we really received little to no guidance from our professors so I am trying my best based off what little I know and can come up with. I mean.. all my classmates and I are scattered wondering how to approach this. Again.. this is my first care plan. My fist month in nursing school. This is a careplan coming from my foundations class, no med surg yet. no pharm yet and I have not started clinicals. so I would only HOPE someone would jump in.

but thanks anyway.

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well of course someone would need to jump in..... I'm a first semester nursing student. This is my first care plan and we really received little to no guidance from our professors so I am trying my best based off what little I know and can come up with. I mean.. all my classmates and I are scattered wondering how to approach this. Again.. this is my first care plan. My fist month in nursing school. This is a careplan coming from my foundations class, no med surg yet. no pharm yet and I have not started clinicals. so I would only HOPE someone would jump in.

but thanks anyway.

I meant I hope someone on allnurses.com who works in critical care can help you with your care plan. I don't work in critical care, & they may have a better response to your question. :)

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LOL... I'm so sorry... it was a misunderstanding. >.

Under a lot of pressure right now. I am becoming acclimated to the world of nursing and my mind is too.

thank you =)

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I am just a third semester student but I would consider ineffective tissue perfusion. If she has/had DKA she probably has a knowledge deficit bc they might not understand "sick day" rules or understand insulin administration. Don't forget your return demo and written instructions. Last, I would pick infection bc infection and illness can lead to DKA. But, that's just where I would start with it. This is usually when a great careplan book helps.;)

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Of course those aren't in order and I would put fluid volume deficit first! ;)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I have a 78 year old female patient (with history of IDDM) who had a medical diagnosis of DKA.

She is nauseous and has been vomiting. She is frequently urinating. Upon assessment I find her to find sunken eyes and a dry burrowed tongue. She has sinus tachycardia. chest xrays reveal infiltrates

Her respiratory rate is 36

Her BP is 92/54

Her pulse rate is 108 bpm

Well we need to have 3 actual diagnoses and I said

Temperature

Respiration

Dehydration

Vomiting/Nausea

I came to the conclusion that the dehydration must be first addressed... but I'm getting it confused ... Now Idk if the vomiting should be first... but then I think temperature must be addressed first... AHH lol.

Well my reasoning is that the temperature could be causing the high respiration, no? If there is a fever the metabolic activities speed up and well that includes breathing because we need oxygen and in this case more to keep up with the high metabolic rate. I figure that the fever could be caused by an infection and if that's so ... How do I(as the nurse) even address that I will fix it? I suppose cold packs? and hydration? HA!!! but then if I hydrate I have already knocked out dehydration .... ermm no?

I know the dehydration is caused by the hyperosmolar nature of the blood due to all the glucose outside her cells which cannot absorb the glucose due to the lack of insulin (IDDM)...

No, not askin' for someone to do this for me. As you can tell I'm very much into this case ... But I need some guidance and clearance.. please (=

Ok.....the critical care jump in.....(wink)

Look at your assess met is there any thing there that concerns you? Is that an OK blood pressure? You mention temp....what is the temp? Think Maslows...what will kill them first. If you cure the dehydration you may stop the vomiting. What else would cause an increase of the respiration's besides a temp? What do you know about diabetic Ketoacidosis? Does hyperventilation help with the acidosis? Can dehydration also cause tachycardia? What part of the physical assessment/appearance also tell you they are dehydrated?

Think Maslows......md0905_01_img_1.jpgwhat will kill them first.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

So using this information what are your nursing diagnoses according to NANDA? Do you have a nursing diagnosis book? I use Ackley and and I use Gulanick. Contributed by vickirn (assistant administrator) pdf.gif nursing diagnoses 2012 - 2014.pdf‎

For example:

Alteration/ineffective in tissue perfusion AEB......

Imbalance is nutrition less than body requirements AEB....

Unstable blood glucose AEB....

Deficient fluid volume AEB...

Risk for shock AEB....

What part or parts of your assessment show eveidence to support these diagnoses?

Do you see where I am going? Look here for more help

https://allnurses.com/nursing-student-assistance/careplan-help-712424.html

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What is DKA? What does it so to the body? What are the symptoms? What could have caused the patient to go into DKA? What did the CXR show? Is there a pneumonia there? Can patients that are very dehydrated have an elevated temp?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

From another post of mine......

The biggest thing about a care plan is the assessment, of the patient. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

The medical diagnosis is the disease itself. it is what the patient has not necessarily what the patient needs. the medical diagnosis is what the patient has and 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.

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 them as a recipe to caring for your patient. Your plan of care.

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

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

  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)

a dear friend to an, daytonite (rip) always had the best advice.......check out this link.

https://allnurses.com/nursing-student...is-290260.html

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.

"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.

"care plan reality: 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). [thanks daytonite]

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). what i would suggest you do is to work the nursing process from step #1

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.

These are prioritized according to think maslow's hierarchy of needs. maslow's hierarchy of needs - enotes.com virginia henderson's need theory

Maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

  • self-actualization – e.g. morality, creativity, problem solving. (to be filled last)
  • esteem – e.g. confidence, self-esteem, achievement, respect.
  • belongingness – e.g. love, friendship, intimacy, family.
  • safety – e.g. security of environment, employment, resources, health, property.
  • physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis. (greatest need to be filled first)

assumptions

  • maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

  • the needs maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
  • growth needs are the highest level, which is self-actualization, or the self-fulfillment.
  • maslow suggested that only two percent of the people in the world achieve self actualization. e.g. abraham lincoln, thomas jefferson, albert einstein, eleanor roosevelt.
  • self actualized people were reality and problem centered.
  • they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
  • they tended to be spontaneous and simple.

application in nursing

  • maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.

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