Need help with my care plan

bigboy18 · Dec 6, 2009

Anyone?!

Disturbedcat · Dec 6, 2009

Impaired gas exchange (this would be the most important problem) your pt has Pneumonia.

cwood88 · Dec 6, 2009

i sent you a htn dx under your quote but I don't see it there now man sorry

thelittlemissus · Dec 6, 2009

your goal statements/outcome aren't measurable. So you need to change that. for dx 2 Pain r/t osteoarthritis your goal statement/ outcome statement would be something like Patient/Client will report pain as 3/10 (this should be whatever is acceptable for your patient) by 12/06/09. Or whatever as long as it is measurable. We also always have to start with patient will or client will, I don't know if you have to or not. you will also need to change your outcomes for the others. For your patient I would go with a dx for the pneumonia but I don't have assessment data to make it. Your related to cannot be to the medical dx either.

Possibly for pneumonia because these would be your most urgent dx remember ABCs

Ineffective airway clearance r/t (tracheal bronchial inflammation, edema formation, increased sputum production, pleuritic pain, decreased energy, fatigue (I'm not sure what's going on with your patient) AEB (changes in rate/ depth of respirations, abnormal breath sounds, use of accessory muscles, dyspnea, cyanosis, effective/ineffective cough-with or without sputum production.

the person above me said Impaired gas exchange which is also good. You could relate this to inflammatory process, collection of secretions affecting oxygen exchange across alveolar membrane and hypoventilation. AEB restlessness/ changes in mentation, dyspnea, tachycardia, pallor, cyanosis, and ABGs / oximetry evidence of hypoxia.

do you have a care plan book or any kind of pda software?

for your risk for infection dx most of the people around here say you don't do related to for risk for instead you do risk factors but if your teachers want r/t just put the same thing--you can not r/t chronic dermatitis--use broken skin or tissue trauma.

Our instructors make us try to think of every nursing dx we can for every patient...if they find something we don't we get more red (there is more that applies here is what they say.). I'm going to stop now, I have like 3 care plans, a psych module and a couple of journal entries to do.

EricJRN, MSN, RN · Dec 6, 2009

Have you assessed the patient yet? Your findings there (as opposed to the patient's hisotry) will be a lot more helpful in pinning down nursing diagnoses.

Daytonite, BSN, RN · Dec 6, 2009

you haven't supplied enough information for anyone to give you much, if any help on any more diagnosing for this patient. see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. that thread has information and many examples of how diagnosing is done. care planning and diagnosing begins with assessment of the patient. while knowing the patient's medical diagnoses (dementia, alzheimer disease, htn, depression, osteoarthritis, pneumonia, chronic dermatitis) is helpful it is only a small part of the assessment. since this is a resident of a ltc facility the services that are given there are nursing care. one of the things that should have been assessed is how the patient's adls are accomplished. adls minimally include bathing, dressing, mobility, eating, toileting, and grooming. this patient has osteoarthritis and pain. is there a mobility problem? do they use some sort of assistive device to walk or need help to get around? there is a diagnosis for that. how is bathing and dressing accomplished? does this patient do it all by themself? i guarantee that if you saw the facility's care plan for this patient it would look nothing like yours. it would have self-care deficits on it and a number of "risk for" diagnoses, all of them based on assessments which you would have found in the chart in the back pages.

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

nursing diagnosis #1

at risk for infection r/t chronic dermatitis

goal/probable outcome

resident will not have an infection

intervention

assess skin q shift

what kind of care are you doing for the skin to keep it from becoming infected?

ensure proper am/hs care is performed - what is "proper" am/hs care?

report/chart any signs of infection - list the specific signs of skin infection that you want detected

apply skin barrier cream to prevent any skin integrity breakdown - where?

there are only 3 kinds of nursing interventions for "risk for" diagnoses:

strategies to prevent the problem from happening in the first place
monitoring for the specific signs and symptoms of this problem
reporting any symptoms that do occur to the doctor or other concerned professional

nursing diagnosis #2

pain r/t osteoarthritis

there are 2 pain diagnoses and you need to specify which one applies here:

acute pain
-
definition
:
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 with an anticipated or predictable end and
a duration of
less than
6 months
.
(page 354,
nanda international nursing diagnoses: definitions and classifications 2009-2011
)
chronic pain
-
definition
:
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
)

goal/probable outcome

pain level will be controlled

interventions

assess res. comfort and pain level

admin meds as ordered from physician

prn meds given to alleviate pain

perform passive rom exercises while in bed to help loosen up the joints, prevent muscle atrophy and maintain muscle tone

see

https://allnurses.com/nursing-student-assistance/nrsg-dx-total-376731.html

-

nrsg dx for total hip replacement

for a list of nursing interventions for pain

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

goal statements have four components:

a behavior
- this is the desired patient response/action you expect to see/hear as a direct result of your nursing interventions.
- you must be able to observe the behavior

[*]it is measurable

criteria that identifies exactly what you are measuring in terms of
- how much
- how long
- how far
- on what scale you are using

[*]sets the conditions under which the behavior should occur

such conditions as
- when
- how frequently
[*]take into account the patient's overall state of health (this requires knowing the pathophysiology of their disease process)
[*]take into account the patient's ability to meet the goals you are recommending
[*]it is a good idea to get the patient's agreement to meet the intended goal so both the nurse and the patient are working toward the same goal

[*]have a realistic time frame for completing the goal

long-term goals usually take weeks or months
short-term goals can take as little time as a day
it all depends on knowing what your nursing interventions are designed to do and what you believe your patient is capable of doing.

deepurple · Feb 1, 2010

what else can be for nursing diagnosis in osteoathritis. if i put on about activity intolerance due to osteoathritis, is it acceptable? or anyone has other suggestion?

Daytonite, BSN, RN · Feb 1, 2010

what else can be for nursing diagnosis in osteoathritis. if i put on about activity intolerance due to osteoathritis, is it acceptable? or anyone has other suggestion?

Did you read what I wrote above? Diagnosing depends on what you have assessed about the patient not necessarily what their medical diagnosis is. It is the patient's response to the osteoarthritis that will be important and I cannot say if Activity Intolerance is one of those responses for this patient. Activity Intolerance is a respiratory and cardiac problem. You've provided no evidence that your patient has any evidence of that. Before you go attaching diagnoses to someone you must understand how the process of diagnosing works. You don't just pull diagnoses out of a hat. You must assess the patient first and then examine the negative assessment evidence to see what fits with the correct diagnosis. What you are trying to do is no different from a medical student attempting to diagnose a medical disease by only knowing that the patient has certain nursing problems. What would you think about a doctor who does that? Not very scientific, is it?

deepurple · Feb 1, 2010

i am weak in doing nursing diagnosis...please help me....my point is i saw that patient cannot tolerate in activity that means he/she needs help from us...he /she also in pain.Any idea?

Daytonite, BSN, RN · Feb 1, 2010

i am weak in doing nursing diagnosis...please help me....my point is i saw that patient cannot tolerate in activity that means he/she needs help from us...he /she also in pain.Any idea?

You have two posts going. I just posted a reply for you to your post on the General Nursing Student Discussion Forum. Please do as I have asked you there. At this point it sounds as if you are really confused or not willing to put any of your own effort into understanding the diagnosis process. I really am trying to help you.