Need care plan help.

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My patient had a transient ischemic attack and came to the hospital ER complaining of severe dizziness and nausea. Her medical history includes hypertension and osteoporosis. After she was admitted an on med/surg, the hospital gave her the diagnoses of cerebellar infarction, bradycardia, and chronic bronchitis, and osteoporosis. There are no labs nor tests that indicate bronchitis or osteoporosis.

We have to make 4 nursing diagnoses based on our patient.

So far I have:

Decreased cardiac output r/t altered heart rate aeb heart rates ranging from 42-56 (this isn't actually how I wrote the data, but there is a lot of it, so this is to make it simple)

Risk for injury r/t tissue hypoxia

Risk for fall r/t dizziness

For each of these diagnoses we have to list 5 nursing interventions within our scope of practice, needless to say, it leaves me grasping for straws trying to find the right interventions. For instance if I said for a patient with a pressure ulcer that I would clean the wound to help promote healing, my instructor would write on my feedback "You didn't do this, so why are you listing it." We are allowed to do wound care, but she won't let us write it as an intervention unless we perform it.

Any help would be appreciated. If you need more information please let me know. Thank you in advance!

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Risk for fall could be bed lowered, call light in reach. Take the pt the the bathroom every 2 hours and before and after meals. Side rails up. Keep everything they need in reach for example water, remote, and phone. Hope that helps.

It's a beautiful day to save lives.

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

What semester are you? Do you have NANDA I or a care plan book? without one of these care plans are unnecessarily hard. Care plans are all about the assessment of the patient. What was your assessment? What does the patient NEED?

What is a cerebellar infarct? What are the symptoms? What is it caused by? What does your patient complain of? What does she need? Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

So......back to square one.....What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. 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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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 the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to 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.

From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

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)

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

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.

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

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.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

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I am a first semester student. I understand the concept of assessing the patient to find their problems; however, I am finding it difficult to put a nanda dx to the patient. The way my teacher has taught me is basically trying to shove a patient into a dx, which isn't correct. We aren't allowed to address patient problems that have already been addressed in the hospital which I feel severely limits what I can dx them with. For instance, if my patient has an electrolyte imbalance that has been 'fixed', we cannot say the patient has an electrolyte imbalance because there is no 'current data' to support the dx. My instructor also doesn't like Nanda dx, and marks us down for "copying" and not being "creative".

The only complaints the patient had were dizziness and nausea.

Her labs (CMP, CBC, Urinalysis) show:

low potassium (3.0)- this has been treated with KCL, so it's out of the running for pertinent info.

high WBC (10.9)

low hematocrit (38.1)

high lymphocytes (5.06)

Urine casts

Urine RBCs at 21.9

Urine WBCs at 6.1

Everything else was normal.

The patient's vitals were :

T 97.1

P 47

RR 18

BP 119/67

O2Sat 98% she was on oxygen 3L at which point she was at 100%

Pain None

The patients later vitals were almost identical

IV is NS @ 75 mL/hr

The patient is a fall risk

On low fat/low sodium diet

Tele reads sinus brady 41

Pt has no known allergies

Pt. states she grew up around second hand smoke

X-Ray shows COPD - bronchitis

On bedrest with bathroom privileges

The patients neurological function was intact.

Oriented x4

Fine and gross motor function and all cranial nerves were intact.

I heard crackles in the lungs, but the nurse told me he had not heard them.

Carotid, radial, and pedal pulses were present.

I just don't get what I'm not seeing here. I'm trying to connect the dots between the assessment and the DX.

The problems (in layman's terms) I find with this patient are:

Bradycardia

Tissue perfusion in the brain

Electrolyte imbalance

Fall risk (dizzy)

Nausea

Are there things I'm not seeing? Am I on the right track?

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Also, I'm working on getting the Nanda book.

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

First I have to comment on your instructor......it makes me angry when instructor throw books out the window....sigh. How are you supposed to come up with a nursing diagnosis without looking it up for each diagnosis/patient problem has certain criteria/characteristics that needs to be fulfilled

What meds is she on? Is she being anti-coagulated? What is her history?

The only complaints the patient had were dizziness and nausea.
Ok there is a NANDA diagnosis for nausea. What happens when a patient has nausea? what are they at risk for if they aren't drinking or eating properly? which of these does your patient fit?

Risk for Injury

Risk for Falls

Risk for Electrolyte Imbalance

Risk for ineffective Cerebral tissue perfusion

Deficient Fluid Volume

Nausea

Imbalanced Nutrition: less than body requirements

Decreased Cardiac Output

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Also if on oxygen, Impaired gas exchange may work

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Oh, good lord, instructors like this make my teeth hurt. (I seem to be saying this a lot lately.)

Your instructor is, alas, dead wrong, if she is really saying you can't use NANDA-I nursing diagnoses out of the book, because they are the only ones that are scientifically validated and accepted after a long process of evidence-based work. You are not free to "be creative" and make them up as you go along. You can be creative in going beyond the student-level easy-pickings of "pain," "impaired mobility," "impaired gas exchange," and the like to find some higher-level problems (for which I would give you high marks). But you can't make them up.

I know Esme and I usually say, "... but they are the ones grading you, not us, so do what they say," but at this point I would consider going to the dean of nursing, bringing the NANDA-I 2012-2014 and any of your work that you have received back that have comments like the ones you describe above, and asking for "clarification." This instructor is not only misleading her students, she's not practicing nursing to the standard of practice of the nurse practice act or the ANA Scope and Standards, which govern us all, and the dean should know about it.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Oh, good lord, instructors like this make my teeth hurt. (I seem to be saying this a lot lately.)

Your instructor is, alas, dead wrong, if she is really saying you can't use NANDA-I nursing diagnoses out of the book, because they are the only ones that are scientifically validated and accepted after a long process of evidence-based work. You are not free to "be creative" and make them up as you go along. You can be creative in going beyond the student-level easy-pickings of "pain," "impaired mobility," "impaired gas exchange," and the like to find some higher-level problems (for which I would give you high marks). But you can't make them up.

I know Esme and I usually say, "... but they are the ones grading you, not us, so do what they say," but at this point I would consider going to the dean of nursing, bringing the NANDA-I 2012-2014 and any of your work that you have received back that have comments like the ones you describe above, and asking for "clarification." This instructor is not only misleading her students, she's not practicing nursing to the standard of practice of the nurse practice act or the ANA Scope and Standards, which govern us all, and the dean should know about it.

I think we can agree that the drive through maters programs are turning out quality material these days....alas I don't have a masters therefore I am no longer qualified to teach....

something's wrong with that picture....:confused:

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I think we can agree that the drive through maters programs are turning out quality* material these days....alas I don't have a masters therefore I am no longer qualified to teach....

something's wrong with that picture....:confused:

*Everything has quality of some kind. :)

You're a good teacher and have found your niche here, and aren't we all glad of it!

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Specializes in INTERNAL MEDICINE, EMERGENCY AND PSYCH.

I feel your pain, i dont want to make it worse by telling you that some facilities now use computers with drop down boxes and no longer use terms such as; Pt will..etc now it's I am a diabetic, I will etc... just makes me scream, given all the emphasis on using proper Dx's.. NANDA however does have a website, with membership options and for students it's free, you just have to pay the verification fee about $50 I think.. check it out.. GOOD LUCK!

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