I have to write a careplan on Nothing !

NurseLoveJoy88, ASN, RN · Apr 9, 2009

it is not true that you have nothing to work with. a care plan is all about determining what the patient's nursing problems are and we use the nursing process, which is a problem solving tool, to do that. i explain how to do this time and time again on this sticky thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. when you sit down to construct a written care plan you are engaging in a logical cognitive process. this is the scientific part of your brain that you need to call into use and emotion needs to be kept out of this process. this is also a time for you to do some independent learning about patient symptoms and procedures that you may not have covered yet in your classes at school.
now, you may not feel that you have much information to work with, but i assure you that you are wrong. the fact is that there are times when you won't have all the information you would like, so you work with what you have. that is where the discipline of using the nursing process will help in rationalizing through the problem.
the first thing i need to suggest that you do is to deal strictly in facts when you work on a care plan. making statements like the following is nonproductive.
"he claims he has had these symptoms for the pas 36 hours or so"
"we do suspect that he is going through withdrawl due to him running out of percocets that he was use to taking daily atc"
"the nurses and docs believes his is a drug seeker a.e.b him being a frequent flyer for the past 4 years and him requesting dilaudid atc."
"he really was a professional pt. he knew exactly what to rate his pain and knew exactly what time he was due for meds!"
"i just know his body depends on a narcotic and his hx shows that everytime he ran out of percocet" - how do you know he is narcotic dependent? what are his physical signs and symptoms?
"this pt. could of made up a story just to get admitted in order to get his dilaudid."
you say, "i'm just not sure if he's a good candidate to work up a care plan on." he's there, he's your patient, he has nursing problems which you just have yet to determine, and you are obligated to care for him. i get that you are frustrated. here is how you use the nursing process to help care plan the problems that this patient has.
step 1 assessment - assessment consists of
a health history (review of systems) - he has told you that he has had nausea and diarrhea for the past 36 hours. he takes percocet for pain for a shoulder cyst and he has run out (or is running low) on them, is obese. has frequent admissions (but you don't say what his other admissions are for).
performing a physical exam - no information. no pain assessment is included. even if you suspected that the patient's pain was not legitimate we must still assess it for documentation purposes and to measure it:

assessment and description of pain includes the following:
where the pain is located
how long it lasts
how often it occurs
a description of it (sharp, dull, stabbing, aching, burning, throbbing)
have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
what triggers the pain
what relieves the pain (was taking percocet and is asking for dilaudid)
observe their physical responses
behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
[*]assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
[*]reviewing the pathophysiology, signs and symptoms and complications of their medical condition - ask the patient about why they have pain and why they are taking these other medications. since their medical records were available, some of their medical history was known.
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking
reglan (metoclopramide) - a cholinergic used for delayed gastric emptying and gerd - one of its side effects is almost immediate diarrhea
zofran (ondansetron) - an antiemetic used for nausea
a muscle relaxant
ambien (zolpidem) - sedative-hypnotic used for insomnia
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data
nausea
obese
diarrhea
pain
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data with the defining characteristics of nursing diagnoses
nausea r/t gastric irritation and pain aeb patient statement of 36 hours of nausea
the related factors are based on the medication that was ordered, the reglan which is generally given for gerd. if the nausea is also due to withdrawal from pain medication then it would be untreated pain that is now causing the nausea. more nausea assessment information for the aeb items would be nice. when people are nauseated they will state they are nauseated, have a sour taste in their mouth or have increased salivation before vomiting.
http://www.emedicinehealth.com/vomiting_and_nausea/article_em.htm - vomiting and nausea
http://www.emedicinehealth.com/chronic_pain/article_em.htm - chronic pain (this link came up when i did a search for nausea)
[*]imbalanced nutrition: more than body requirements r/t eating more than metabolic needs aeb [needs evidence]
do you have a weight or bmi?
[*]diarrhea r/t adverse effect of medication aeb patient statement of 36 hours of diarrhea
more diarrhea assessment information for the aeb items would be nice. the abdomen would have hyperactive bowel sounds. patients having diarrhea also get abdominal cramping and an urgency right before having to go to the bathroom. was this asked of him?
http://www.emedicinehealth.com/diarrhea/article_em.htm - diarrhea
[*]acute (or chronic) pain r/t inflammatory process in shoulder aeb [pain assessment]
the pain is acute if it is less than 6 months in duration. if it is over 6 months it is chronic.
the related factor is the reason (cause) of the pain. this information could possibly be found in the doctor's h&p or the old records. it might be the shoulder cyst. before dismissing this as the source, let me tell you about a patient we had years ago who had over 100 admissions for pain related to hand-shoulder syndrome (hss) who was addicted to narcotics. we all scoffed at the diagnosis and all the narcotics ordered for him, too. but, the fact was, i realized years later, his pain began originally with the hss and that was the original source of the problem for the pain regardless of the fact that he became addicted to narcotics because of it.
pain assessment needs to be developed. for instance, he would probably say his pain is 10 on a scale of 0 to 10. you still need to state that. look at the assessment information i gave you above. even if addicted, these patients still have physical symptoms when they need their medication and we have to assess for that.
[*]anxiety r/t narcotic use aeb [nausea and diarrhea]
but i bet if you go through the defining characteristics of this diagnosis that you will find a number of symptoms that this patient displayed that you missed picking up on. see this website: anxiety
read about tolerance vs. addiction as well the signs and symptoms: http://www.emedicinehealth.com/narcotic_abuse/article_em.htm - narcotic abuse
[*]risk for deficient fluid volume r/t fluid loss because of diarrhea
step #3 planning (write measurable goals/outcomes and nursing interventions) - now write the goals and interventions that target the aeb items that go with each of the diagnoses.
and nowhere in this diagnosing did i mention anything about this patient lying about his symptoms, being noncompliant, or addicted. and, as you can see, there was plenty there to come up with 6 diagnoses. with more assessment information more diagnoses are probably there.

thanks !!!

NurseLoveJoy88, ASN, RN · Apr 9, 2009

Can I use the following: More than body requirements aeb pt. weights 328lbs , and Less than body requirements aeb pt. reports persistant diarrhea and vomiting for 36 hours. Will these two diagnoses cancel eachother out ?

Daytonite, BSN, RN · Apr 9, 2009

can i use the following: less than body requirements aeb pt. reports persistant diarrhea and vomiting for 36 hours?

this is not an appropriate diagnosis with the proper evidence supporting it. all actual nursing diagnoses have defining characteristics (signs and symptoms). imbalanced nutrition: less than body requirements is defined as intake of nutrients insufficient to meet metabolic needs. persistant diarrhea and vomiting for 36 hours does not meet the criteria for this diagnosis and persistant diarrhea and vomiting for 36 hours are not nutrients. when you are learning to diagnose you need to be using a diagnosis reference to check the definition, related factors and defining chacteristics of each diagnosis you use. if you do not have a nursing diagnosis reference or a care plan book that includes this information you will find it in the appendix of taber's cyclopedic medical dictionary. approximately 80 of the most commonly used nursing diagnoses and the nanda information about them is included on these two websites:

see these webpages: imbalanced nutrition: less than body requirements and

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=37