Need help in making Care plan

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Hi every1,

Need help in making a care plan for a patient with CAD and vitreous hemorrhage in the left eye? Patient also has diabetes type II.

I am a little bit at lost here. Would appreciate any help.

Thanks. :)

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

Welcome to an! the largest online nursing community!

ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit them into the diagnosis. 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.

What is your assessment? What are the vital signs? What is the neuro assessment. 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.

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.

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.

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.

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

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:

  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)

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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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.

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 (ex: activity intolerance) is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis

definition: insufficient physiological or psychological energy to endure or complete required or desired daily activities

(does this sound like your patient's problem?)

defining characteristics (symptoms): abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness

related factors (etiology): bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle

i've just listed above all the nanda information on the diagnosis of activity intolerance from the taxonomy. only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.

one more thing . . . care plan reality: nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. they are all linked together with each other to form a nice related circle of cause and effect.

you really shouldn't focus too much time on the nursing diagnoses. most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. the nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.

a dear an contributor daytonite always had the best advice.......check out this link.

https://allnurses.com/nursing-student...is-290260.html]

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

Need help in making a care plan for a patient with CAD and vitreous hemorrhage in the left eye? Patient also has diabetes type II.

Now.....you need a good care plan book I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

Now...the care plan. This is the recipe card for how to car for your patient. Is this a real patient? If so....what does the patient complain of? Are they in pain? Are their blood sugars under control? What meds are they on?

What is CAD? What is a vitreous hemorrhage? What causes it? What is Diabetes type II? Is your patient obese? Do they have chest pain? What are their vital signs?

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Thanks for your response guys. Its a fictional case. I would have done some assessment myself had I had the real patient with me, Sorry I know I should have been more detailed about it.

The History given to us is that, Patient has HTN, with diabetes type II which is controlled, patient is admitted due to Tachycardia. Found to have blockage of coronary artery. Patient is not obese and has complaint of weakness, headache, Impaired mobility and shortness of breath.

patient was found to have vitreous hemorrhage in the left eye.

takes medication for angina.

Patient has edema in bil feet and OA

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Thanks for all those links.

Nice.

:)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Patient has HTN, with diabetes type II which is controlled, patient is admitted due to Tachycardia. Found to have blockage of coronary artery. Patient is not obese and has complaint of weakness, headache, Impaired mobility and shortness of breath.

patient was found to have vitreous hemorrhage in the left eye.

takes medication for angina.

Patient has edema in bil feet and OA

Grrrrrrrr..:madface:....I hate it when the instructors can't be more creative and give the information you need to properly do a care plan. For in reality the care plan is based off assessment and patient complaints. Grrrrrrrr....:banghead: Defeats the purpose of a care plan.

Ok.....first you need to know what CAD is and what the symptoms are. Medscape: Medscape Access Medscape is a free medical site that gives excellent information and references/resources....no strings attached. It would be in your interest to register.

Coronary artery disease - MayoClinic.com

CDC - DHDSP - Heart Disease - Coronary Artery Disease

Medscape: Medscape Access

Then what is Type II diabetes and what complications can that cause. Then vitreous hemorrhage. I would look up heart failure as well due to the LE edema/tachycardia and SOB.

Then you can develop a hypothetical nursing diagnosis on that.

You are told the patient has a blockage so they will possibly have pain.

So your patient has tachycardia. They are weak have a headache, can't walk very far and are SOB. What nursing diagnoses do you need.

They have alteration in comfort.....due to chest pain? Headache? SOB. They are having difficulty with their ADLS because of the impaired mobility? Right? Is the headache possibly caused by an elevated B/P? as evidenced by the vitreous hemorrhage of the eye? what is the vitreous hemorrhage? They have edema and shortness of breath.......is this a possible sign of heart failure? Would that be right or left heart failure given the symptoms? Would the heart failure also cause the weakness, and impaired mobility? Could the feet be so swollen that they impair mobility?

Is the tachycardia caused by the CAD/HTN/coronary blockage? would full lungs that cause SOB cause the heart to beat faster? Is this a sign of distress?

They also have a knowledge deficit about possible new heart failure but about a interventional procedure as well.

Does this make sense?

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

So knowing these things what measures would you take to care for this patient.......O2? I/O daily weights? vitals? Use your care plan book to look of the defining characteristics and intervention/measurments/implementations.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thanks for your response guys. Its a fictional case. I would have done some assessment myself had I had the real patient with me, Sorry I know I should have been more detailed about it.

The History given to us is that, Patient has HTN, with diabetes type II which is controlled, patient is admitted due to Tachycardia. Found to have blockage of coronary artery. Patient is not obese and has complaint of weakness, headache, Impaired mobility and shortness of breath.

patient was found to have vitreous hemorrhage in the left eye.

takes medication for angina.

Patient has edema in bil feet and OA

Actually it's just me......I'm all the guys....:lol2:

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thanks man. Much appreciate it.

:jester:

feel like a clown.

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

Don't feel like a clown......it's all good no judgement here!

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