Nursing Care Plan Diagnosis Help!

[phoneix86]

Hello. Im new to the site and I was hoping to get some help with finding 5 diagnosis for my care plan. here is the info i have

Developmental:

Integrity Vs Despair

Friendly, smiles

Open and talkative

Grandparent

Retired

Worked 25 years as nursing assistant.

Client states, "I liked doing it, loved the people."

Able to perform ADLS

Mother

Client stated, " I have 5 children, 4 girls, 1 boy and 9 grandchildren and 5 great grandchildren."

Senior Citizen (71 years old)

Cultural:

Mother

Moved here from Kentucky 50 years ago and now lives locally with her oldest daughter who is 51 years old.

All but one child lives locally. One daughter lives in Madison.

Caucasian American

Speaks English fluently

Medicare/Medicaid

Client has a large support group made up of friends, family and church members.

Client enjoys spending time with friends and family, for leisure activity. Client stated " I like going shopping, having lunch with my friends, going for walks going to church and helping watch my great-grandson."

Family members are willing to help client meet her personal needs.

1800 Diet

Grandparent

Client states " My great-grandson has cerebralpalsy and I help out with him. I go set with him, help him with what I can and things."

Client is a widow. Client states "My husband passed about 5 years ago."

Client has mild sight sensory deficit requiring the need for eyeglasses while reading only.

Psychosocial

Family support of children, friends and church. Client states, " I have had a lot of visitors, my kids, niece, friends, people from my church. "

Effectively coping, voices acceptance of condition, talks openly about previous surgeries, and medical diagnoses.

Client is very talkative, engaged in conversation, smiles, and displays polite and compliant behavior.

Client is very pleasant.

Client is awake, oriented, speaking coherently, and is calm.

Client is clean in appearance.

High School Graduate

Client states " I wish I had went to college. You do not realize that until your older."

Spiritual:

Stated Belief in God

Baptist religious affiliation

Attends Church every Sunday

Client prays

Physiological:

Oriented

BP 132/67

Temperature 97.3

Pulse 78

Respirations 18

Pulse Ox 95%

Able to perform ADLS

Does not Drink Alcohol

NKA

Influenza Vaccination Current

Could Go Home Today

Skin pink, warm, dry, no rashes

600 ml breakfast fluid intake, client ate 100% of breakfast.

Normal Heart Sounds

167.64cm Height, 78.10 weight, BMI 28.9

Overweight

2008 Diagnosed with Breast Cancer

Chemotherapy treatments for Breast Cancer

Type 2 Diabetic

Glucose 384

70/30 Lantus Flex Pen 15 units

Humulin R/Novolin R 2-10 units

Insulin Sliding Scale

BS 121-150 2 units BS 151-200 4 units

BS 201- 250 8 units BS 251-300 10 units

BS >350 Call MD

Dentures upper and lower

Neck Surgery

Cholecystectomy

Bronchoscopy

Fibromyalgia

Peripheral Neuropathy

Thyroid disorder

Pneumonia

Receiving Anticoagulant Therapy

Nasal Cannula 2L

COPD Wears oxygen at night

Anxiety

Lumpectomy Right Side

Limb Alert Right Side

Hypertension

Saline Lock

Smokes 1 ½ packs daily

K-Dur 20meq PO QD AC

Deltasone 40mg PO

Crestor 10mg PO QD

D5W 50% bolus 25ml

Glucagon 1mg

Lortab 7.5/500 1tab PO Q6H PRN

Zofran Sublingual 4mg PO Q6H PRN

Alprazolam 0.5mg PO TID

Unasyn 3GM IV Q8H

Lovenox 40mg SC QD

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[TD]PLATELETS 272,000

RBC 5.01

WBC 10.7

HEMOGLOBIN 13

BUN 9MG/DL

CREATININE 0.7MG/DL

CALCIUM 8.8 MG/DL

SODIUM 141 MMOL/L

POTASSIUM 3.1 MMOL/L

CHLORIDE 101 MMOL/L

CREATINE KINASE 165 U/L

TROPONIN

Family History:

Diabetes

Hypertension

Breast Cancer

Reason for admission:

pt stated " i am having trouble catching my breath" chart medical diagnosis said Pneumonia

I have a lot of info, not sure if I have it all in the correct places, as well as I'm not sure what to pull for diagnosis. My professor said one of my diagnosis should be knowledge deficit r/t home care but i don't know what the AEB would be?? This is my second care plan so I'm still struggling and learning so any advice or corrections would be great!

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[ParkerBC,MSN,RN, PhD, RN]

Do you have a nursing care plan book? Most provide AEB sections for you. Of course you can tweak them if needed, but they provide a starting place.

[Sheryl18]

This pt has pneumonia and COPD, I would address that as a priority diagnosis. I would also come up with a diagnosis for the diabetes. Ummm and smoking 1 1/2 packs a day with COPD and on O2 at night at home, I'm guessing maybe that's where your instructor was going with the knowledge defecit. There are definately more diagnosis' that you could address too. Do you have a care plan book? Good luck!

[nurseprnRN, BSN, RN]

you don't make a nursing diagnosis from a medical one, you make it from your own nursing assessment. (esme, where are you with all daytonite's great care planning stuff?) you look like you've done a bang-up job on that, so now is when you pull open your nursing diagnosis and care plan book and see if anything you found, any of your data, are defining characteristics for any nursing diagnoses. if you don't have the nanda-i 2012-2014, now's as good a time to get it as any, and it will make your life much easier. available at your favorite online bookseller, and i hear they do free 2-day shipping for nursing students if you ask.

i'm thinking you might want to look in the index for something to do with breathing, since she's short of breath and has pneumonia already. does she have lung metastasis from her breast ca?

depending on what she knows about her meds, she might need teaching about them, and even if she does, a refresher is usually a good idea.

what are her meds for? can you identify one that she really needs to know about, actions and side effects, and how to recognize them and when to call her primary care with an update?

did your professor talk to this lady and ask her some questions? it might be ok to ask her how she diagnosed a knowledge deficit about home care; if she tells you, that's your evidence that it exists. or does she think that this patient might have this diagnosis, and wants you to investigate further by asking her questions? data first, diagnosis second, not the other way around.