Need help with careplan

[fishchick72]

Ok, I'm not sure how other schools do care plans, but at my school we FIRST do a "care map", the box in the center of the page starts with the medical dx, then for each system or area involved you start a box & put all the abnormal data you have in each box. SECOND we do an opening statement on the pt & then do a cluster of info on each system affected. THIRD we do the actual careplan with the nursing dx, r/t, & m/b.

I am trying to do a careplan based on a one paragraph scenario. The pt has exacerbation of CHF. My first cluster is on cardiovascular, the second cluster is on pulmonary, I am struggling with the third cluster. I started to do mobility (activity intolerance), but can't come up with any data to put in the cluster.

Any suggestions?

[npbellydancer]

how about a pot alteration in self care r/t activity intolerance secondary

[fishchick72]

how about a pot alteration in self care r/t activity intolerance secondary

but still, what info do I list in my cluster, it's not the dx that I'm struggling with, it's getting abnormal data to list in the cluster & then I have to specify what treatment is done for it & how effective the treatment is.

[suebird3]

Is the "patient" winded after exertion? Can they only walk so far w/o having to rest?

Suebird

[fishchick72]

Is the "patient" winded after exertion? Can they only walk so far w/o having to rest?

Suebird

Yes, it's not real specific, but does state sob upon rest even. I am allowed to make up what I need to that isn't stated, I just don't know what else I can make up for this.

[Daytonite, BSN, RN]

Just some thoughts. . .

Musculoskeletal could be inability to tolerate weight, atrophy of muscles resulting in inability to walk correctly, loss of muscle tone

Circulatory problems with activity intolerance are edema in the lower extremities and the development of blood clots or even phlebitis, SOB

Neuro might aggravate conditions such as the ability to maintain balance

GI results would include constipation

Integumentary would probably involve things like excessive sweating because of the activity intolerance which can lead to other problems of the skin if it is not cleansed properly afterward.

[suebird3]

Yes, it's not real specific, but does state sob upon rest even. I am allowed to make up what I need to that isn't stated, I just don't know what else I can make up for this.

Inability to ambulate......... good beginning here. If there is a Barnes and noble near by, they may have a few care plan books to help.

Suebird

[fishchick72]

Thanks everyone for your help!! I do have a careplan book, but like I said the careplan wasn't a problem, it was the darn cluster thing we have to do. I was able to pull it off doing the first cluster as oxygen:cardiovascular (decreased cardiac output r/t CHF m/b edema to BLE), the second cluster as oxygen:pulmonary (ineffective breathing pattern r/t pulmonary edema secondary to CHF m/b SOB & increased RR), & the third cluster as mobility (activity intolerance r/t SOB secondary to CHF & pulmonary edema m/b SOB at rest & inability to walk > 10 ft. with PT).