Not asking for anyone to do my homework I just need some assistance with a care plan.

Daytonite, BSN, RN · Feb 11, 2009

you work with the information that you do have. the first thing i do is go through the information that someone posts about a patient and pull out all the abnormal data. patient problems, which get converted into nursing diagnoses, are based upon the abnormal data that you have. we are not the only profession that bases our conclusions upon abnormal data (evidence). plumbers, car mechanics and police detectives do it all the time. plumbers and car mechanics must track down a problem just as we do knowing only what the symptoms are and sometimes looking for even more to help clarify what is going on. police detectives know the name of the problem (the crime) by identifying it features, but cannot arrest someone without having the evidence to support that they are the person who did the crime, so they are working things a little differently but still dealing with evidence and a problem. we have evidence but are in search of a name, or names, for it (nursing diagnoses). when police detectives put the crime, the criminal and evidence together they have a case. when we put the patient, the evidence and problems together along with nursing interventions we have a care plan. and in all situations whether you are a plumber, car mechanic, police detective or a nurse, you are using logical reasoning, or what nursing instructors fondly call critical thinking to accomplish this.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - one of the first things you need to do even though you spent very little time with this patient is look up the pathophysiology and the signs and symptoms of chf. this information is needed in order to understand why the patient has congested lungs and how the htn is related. chf is one of the most common heart problems that patients have along with htn. this patient has some classic signs of chf. https://allnurses.com/nursing-student-assistance/medical-disease-information-258109.html - medical disease information/treatment/procedures/test reference websites hasall kinds of helpful weblinks to help you find information. the list was actually expanded from a lpn school help site. i would look up chf in the merck manual (you will find the weblink there). there is also information about hypertension that you need to know about htn:

blood pressure consists of two main components:

cardiac output
- heart rate
  - beats per minute :redbeathe
- stroke volume
  - amount of blood pumped per beat
[*]
peripheral resistance
- resistance of the arteries against the flow of blood through them

increasing/decreasing

any one

of the above factors increases the blood pressure and vice versa. there is only one nursing diagnosis that specifically pertains to cardiac function:

decreased cardiac output
- decreased cardiac output
- http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=09

so, your patient's medical diseases and medical treatments are:

severe chf exacerbation
uncontrolled htn
treatments
- o2 6l

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - i pulled out all the abnormal data from what you posted and grouped it together by respiratory symptoms, heart/circulation systems, his level of orientation and communication ability. i specifically grouped them in that order because of maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). here is the list:

crackles and wheezes in both lungs
shallow respirations
thready pulse
low b/p
very lethargic
hard to wake and was pretty much out of it
unable to communicate

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - now that list just above is evidence that supports (proves) the existence of the nursing problems that i am going to name. every nursing diagnosis has a list of what nanda calls defining characteristics (signs and symptoms). that abnormal assessment data in the list above will be some of the defining characteristics of nursing diagnoses that i will end up using. nursing diagnoses are not like medical diagnoses where a patient must have all the signs and symptoms. the patient merely needs to have at least one, possible two of the defining characteristics (signs and symptoms) of a nursing diagnosis and you are good to go. knowing the pathophysiology of their medical disease, some of the patient's history and the cause of their disease condition is going to help you determine what the etiology ("related to" part) of the diagnosis will be.

impaired gas exchange r/t ventilation perfusion imbalance aeb thready pulse, low b/p, very lethargic, hard to wake and was pretty much out of it
ineffective airway clearance r/t retained secretions aeb crackles and wheezes in both lungs and unable to communicate
psychosocial: impaired verbal communication r/t decreased oxygenation to brain aeb unable to awaken and communicate with patient

the nursing interventions target the aeb items attached to each nursing diagnosis. the goals will be what i anticipate will happen as a result of performing those nursing interventions.

excess fluid volume related to decreased cardiac output

the problem here is that decreased cardiac output cannot be an etiology of

excess fluid volume

.

excess fluid volume

is due to excess fluid intake or retained fluid. decreased cardiac output, as i explained above, is rather complex and has a number of factors involved in it so it cannot be an underlying cause of an excess fluid volume

.

activity intolerance related to generalized weakness

the problem with diagnosing this is that there is no evidence to prove it exists. there must be several things happening for

activity intolera

nce to exist. the patient must not only get fatigued/weak but it must occur with activity and there must be changes in their heart rate, respiratory rate and b/p during the activity that causes them to stop the activity. while this usually does happen with chf patients, i didn't see anything in your post about this happening with this patient. with the crackles and wheezes in his lungs i feel he has more of a gas exchange and airway clearance problem that takes priority.

knowledge deficit related to cognitive impairment

i saw no evidence of a problem or need in this area. also, you posted that the patient was pretty much out of it so it would seem futile to diagnose and attempt to teach him anything, wouldn't it? does the patient really have a cognitive impairment? (what does that mean? retarded? low iq? it needs to be explained.) that wasn't in the information you posted.

Peachez8207 · Feb 12, 2009

Daytonite you are amazing. I mean truly amazing. Thank you so much for all of your help. I am going to chek some of the links you have previously posted and try to get a deeper grasp of writing these care plans. I have 2 more left but I have some time before they are due so maybe I will get the hang of them.

Once again Thanks!

Crystal