My nursing care plan...acceptable or needs some correction or other ideas

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Nursing diagnosis - Activity Intolerance due to osteoarthritis

Objective - Patient can tolerate with minimal help by nurses in ADL's.

Interventions

1.Assess patient's level mobility. This is can help nurses to plan in helping patient to tolerate with minimal help.

2.Assess patient or caregiver's knowledge of immobility and its implications. Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown or muscle weakness.

3.Assess potential for physical injury with activity. Side rail up to prevent fall that lead to injury. Teach patient/caregivers to recognize signs of physical over activity. This promotes awareness of when to reduce activity.

4.Teach energy conservation techniques by changing positions often. This distributes work to different muscles to avoid fatigue.

5.Anticipate patient's needs which are keep the call bell within reach to get any help from nurses like pass urine.

6.Turn and position every 2 hours or as needed that can optimizes circulation and relief pressure.

7.Allow patient to perform task at his or her own rate to build up the self-esteem on an independent as able and safe.

8.Provide positive reinforcement during activity. Patients may be reluctant to move or initiate new activity due to a fear of falling.

Can anyone here help me to check whether my nursing care is acceptable or not...If corrections are necessary,please correct it for me or some other suggestions or ideas that can be put on.i hope i can learn more from my mistakes.

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

i would love to help you, but cannot provide specific assistance for the same reason i gave you in your other post. you have not provided the supporting evidence for why this patient has activity intolerance. your interventions would be treating that supporting evidence and i have no way of knowing what you are treating here.

as i said in my other post, activity intolerance is a respiratory and cardiac problem--not a physical activity problem. it's definition is: insufficient physiological or psychological energy to endure or complete required or desired daily activities (page 134, nanda international nursing diagnoses: definitions and classifications 2009-2011). what that means is that when the patient attempts any activity they usually end up having to stop and sit down because they have symptoms of elevated heart and respiratory rates. they get sob and must stop what they are doing because of it. you need to read the defining characteristics (symptoms) that go with this diagnosis in a nursing diagnosis reference. if you do not have one you can see them on these two websites:

you may have inaccurately misdiagnosed this patient's problem. the nursing interventions you have listed do not match up with symptoms of sob and some of them have to do with risk for impaired skin integrity and impaired physical mobility.

please read the information on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. rethink your diagnosis. you must list out any supporting evidence before deciding on a diagnosis. goals and interventions must relate back to that supporting evidence. goals reflect what you expect the patient will do as a result of your interventions being performed. then post what you have and i will be happy to check and correct what you have come up with.

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thank you for your reply...i don't have any idea to do nursing diagnosis relate to patient which has osteoarthritis and total knee replacement. when i observed the pt,i saw she cannot walked down from the bed,cannot go to the toilet independently,when move her leg,she felt pain...all about causing pain to her..so is it still cannot acceptable if i put nursing diagnosis related to pain?.For example,altered comfort due to pain or altered mobility due to pain. Are these correct or need correction? please help me to write better nursing diagnosis for my case study. This is the first time i had assigned by my tutor to do case study. please help me if i was wrong...:confused: :crying2:

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dear daytonite...i had tried to do nursing diagnosis related to pain....please help me with this nursing diagnosis as below...

nursing diagnosis - altered comfort due to acute pain caused by osteoarthritis.

objective - patient will able to cope with incomplete relieved pain when rest in bed.

nursing interventions

1.assess pain characteristics by pain score which scale 0-10 which 0 is no pain and 10 indicates most severe pain.

2.observe or monitor signs and symptoms associated with pain, such as bp, heart rate, temperature, color and moisture of skin, restlessness which are help nurse in evaluating the pain.

3.provide rest periods to facilitate comfort, sleep, and relaxation. the patient's experiences of pain may become exaggerated as the result of fatigue.

4.provide analgesic to patient as doctor ordered to relieve pain

5.arrange the procedures to the patient at a time to give rest and relax to patient in bed that encounters the pain.

6.provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain.

i need help from others in my nursing care. i just can do till these part but i still not satisfy.still need to put on but i had already no idea.anyone can give me some idea or suggestion.

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I am just thinking out loud here as I don't start writing care plans for several days yet.

The first thing that comes to my mind is Impaired Physical Mobility.

Maybe that is a place to start since osteoarthritis affects the joints.

If I am wrong someone please jump in so I do not waste someones time sending them down the wrong path.

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

when care planning you need to follow the steps of the nursing process. . .

step #1 - assessment - nursing assessment consists of

  • a health history (review of systems) - all you've told me is that this patient has osteoarthritis and has had a total knee replacement
  • performing a physical exam - no physical exam data provided. if you are doing a care plan about the patient having pain you need to assess her pain. you provide no pain assessment. you cannot do any later goals or evaluations if you don't even know what the patient's beginning pain assessment was!
    • 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

        [*]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) - you state that she cannot walk from the bed or go to the toilet independently, but do not say what kind of nursing assistance she needs. does someone have to help her? how, specifically? can she weight bear on the leg that had the surgery? does she use a walker or cane? these things are an important part of the assessment.

    [*]reviewing the pathophysiology, signs and symptoms and complications of their medical condition - part of assessing is looking up and learning about the patient's medical disease and the medical treatments that have been performed on them. you need to look up and learn about osteoarthritis, its pathophysiology, signs and symptoms and complications. does your patient have any of its symptoms? look up the procedure of a total knee replacement. was it done because of the osteoarthritis? what are the expected outcomes of this surgery? what are possible complications of it that you need to observe for?

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what medications is this patient being giving and what are their side effects? is she getting something for the osteoarthritis? is she getting anything for her pain? is she getting any physical therapy?

step #2 determination of the patient's problem(s)/nursing diagnosis - after collecting all the data above and sorting through it, you separate out the data that is abnormal. for example, having pain when moving the leg is not normal. not being able to go to the toilet independently is not normal. not being able to walk is not normal. i am sure after doing a more thorough review of the data there may be other information you will find that is not normal about this patient. this "clues" are the symptoms of her nursing problems which you will then attach names called nursing diagnoses to, such as

  • chronic pain
  • impaired physical mobility
  • toileting self-care deficit

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals and nursing interventions are based upon the evidence that supports the nursing problems. just as a doctor treats the signs and symptoms of a medical disease, we nurses also treat the signs and symptoms of the nursing problems. your goals are what you predict will happen as a result of your nursing interventions being performed. as you can see everything in the plan of care is very closely tied to what has come out of your assessment data.

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

nursing diagnosis - altered comfort due to acute pain caused by osteoarthritis.

this is not a current official nanda diagnosis. the current diagnosis would be
chronic pain
secondary to osteoarthritis
. medical diagnoses cannot be included in nursing diagnostic statements unless they are worded this way. also, osteoarthritis is a chronic disease and this pain has been with the patient for a long time. the definition of
chronic pain
is as follows:
unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (international association for the study of pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration
of more than 6 months
.
(page 355,
nanda international nursing diagnoses: definitions and classifications 2009-2011
). the diagnosis would be
acute pain
if her pain were
less than 6 months
.

objective - patient will able to cope with incomplete relieved pain when rest in bed.

this is not an appropriate way to word a goal or outcome. first of all, we have the problem of no assessment data to base this on. secondly, what does "incomplete relieved pain" mean? you have interventions asking for specific pain scoring on a scale of 0 to 10 and you are going to accept something as hazy as "incomplete relieved pain" for a goal? that's not very scientific. third, the data you did provide me said that she had pain when she moved her leg. that does not fit with resting in bed.

nursing interventions

1.assess pain characteristics by pain score which scale 0-10 which 0 is no pain and 10 indicates most severe pain.

2.observe or monitor signs and symptoms associated with pain, such as bp, heart rate, temperature, color and moisture of skin, restlessness which are help nurse in evaluating the pain.

3.provide rest periods to facilitate comfort, sleep, and relaxation. the patient's experiences of pain may become exaggerated as the result of fatigue.

this is not a pain intervention and does not belong here. it is for fatigue, another nursing problem.

4.provide analgesic to patient as doctor ordered to relieve pain

5.arrange the procedures to the patient at a time to give rest and relax to patient in bed that encounters the pain.

this is not a pain intervention and does not belong here. it is for fatigue, another nursing problem.

6.provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain.

this is a list of examples of interventions for pain:

  • assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
  • assess and document where the pain is located and what, if anything, makes it worse or better - in your entire care plan for pain i do not know where your patient's pain is. in fact, i don't know anything about this patient's pain because you have told us nothing about it. when i read your care plan i should know where your patient's pain is and what the patient is experiencing--i get none of that from your care plan.
  • observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
  • give pain medication as ordered
  • provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
  • reposition the patient
  • give a back massage
  • use short, simple relaxation exercises to distract the patient's attention
  • dim the lights in the room and keep noise down
  • play soft, soothing music
  • have the patient perform slow deep breathing and concentrate on feeling weightless with each breath
  • reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
  • monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting
  • teach the patient about prescriptions they will be going home with including the dosage, how they should be taken and any side effects

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Past medical history - patient had already done the total knee replacement at left leg.

Current history - patient now on total knee replacement at right leg.

She felt pain due to osteoarthritis that she had.

As i said she cannot move due to pain.She needs help from others if she wants to pass urine.She asked for bedpan. She had no power to walk although there are someone that can help her to move. She admitted to ward by wheel chair.She scared to turn her body position due to pain. She cannot sleep because she felt pain and always thinking about surgery.She can't wait for operation because she can't bear of her pain. Doctor ordered Morphine for her to relieve her pain.

Are this data enough for me to do nursing diagnosis?

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

your data is vague. i gave you a whole bunch of information on how to assess pain. did you read it? still all you can tell me is "she cannot move due to pain", "scared to turn her body position due to pain", "cannot sleep because she felt pain", "she can't bear pain". what is her pain on a 0 to 10 scale? where is her pain? i am still wanting to know that. is her pain sharp, dull, stabbing, aching, burning, throbbing?

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Specializes in Geriatrics, Pain, End of Life Care.

As I pass by this thread, my mouth is agape in awe and wonder at your wisdom. Out in "the world" care plans can get so rote and systematized...your post and challenge to this new nurse inspires me to greater heights. thanks!

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she feels pain at her knee...and scale is 7..

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

I checked, corrected and gave suggestions for both care plans you posted. Is there something else you want?

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