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Nursing care plan- Health Promotion

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Hi all,

I am currently working on a nursing care plan and am stuck unfortunately. My patient has COPD with pneumonia. So I wanted to do readiness to enhanced immunization status r/t desire to improve health evidenced. I am having trouble coming up with interventions.

short goal- Patient express knowledge on the importance of vaccines esp pneumococcal.

long goal- Patient receive recommended immunizations yearly...

Interventions-

Short: Assess patient's perception of the pneumococcal immunization.

Educate the patient on risk factors of receiving the pneumococcal vaccination.

Discuss the risk factors that increase the likelihood of developing pneumonia.

Long: Having difficulty with...

Any suggestions? Thanks!!

Maybe implement mechanisms to contact client/caregiver for yearly reminders, but that (and pretty much everything else I read) wouldn't be used by a floor nurse in a hospital, a nurse or MA in an office would. I'm not sure how your program is but I just wanted to put it out there that if I had a COPD patient with pneumonia and tried to do my care plan on that diagnosis they would make me redo it (or just fail me). They always need to be focused on 1. the most important/significant problem/diagnosis and 2. Things we can actually do for the patient during our shift. Ineffective airway clearance, activity intolerance, impaired gas exchange, imbalanced nutrition would all take a much higher place in what to be concerned about. Just something to think about if you haven't already, I'd hate to do all that work just to have to do it all over again!:)

Edited by nlynrob

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

First.... has the patient verbalized a desire to improve immunization status? What semester are you?

eEery ND has a definition and a list of symptoms or related factors that the patient must fit into in order to use the diagnosis.

Readiness for enhanced Immunization Status

NANDA-I Definition: A pattern of conforming to local, national, and/or international standards of immunization to prevent infectious disease(s) that is sufficient to protect a person, family, or community and can be strengthened

Defining Characteristics: Expresses desire to enhance behavior to prevent infectious disease; expresses desire to enhance identification of possible problems associated with immunizations; expresses desire to enhance identification of providers of immunizations; expresses desire to enhance immunization status; expresses desire to enhance knowledge of immunization standards; expresses desire to enhance record keeping of immunizations

You patient must have at least one defining characteristic to use this diagnosis.

Your ND statement....

Quote
readiness to enhanced immunization status r/t desire to improve health evidenced.

Needs work.....your patient has readiness to enhanced immunization stated R/T ___________as evidenced by__________.

Every care plan is all about what the patient needs....about the patient assessment. Tell us about your patient.

The defining characteristics, one of which you must identify in your patient to make this nursing diagnosis, include the following:

  • expresses desire to enhance behavior to prevent infectious disease
  • expresses desire to enhance identification of possible problems associated c immunizations
  • expresses desire to enhance identification of providers of immunizations
  • expresses desire to enhance immunization status
  • expresses desire to enhance knowledge of immunization standards
  • expresses desire to enhance record-keeping of immunizations

I will leave it to you to look up the actual definition of the diagnosis, because you don't sound clear on that either.

There are no causative factors (related to) in this diagnosis.

You can't just make it up as you go along because it sounds like something you think is needed or sounds reasonable. You must refer to an (actually, THE) authoritative nursing diagnosis work, the NANDA-I 2012-2014. $29 at Amazon, free two-day delivery for students. Order it tonight (Monday) and have it by Wednesday, and never make those mistakes again.

Hi thank you for your response, My care plan has 3 parts.

For the actual- Infection rt secretions in lower left lobe evidenced by crackles.

Risk- risk for falls rt impaired physical mobility evidenced by pain in lower left thoracic cavity and peripheral neuropathy.

Health Promotion- Readiness for enhanced nutrition rt desire to improve evidenced by low calorie intake but expresses willingness to enhance nutrition.

This is what I had at first but my patient did mention stuff about the pneumococcal vaccine. Especially since she has a history of pneumonia. But I was having difficulty figuring out what to write/goals/interventions.

Patient is 78 History- COPD, HTN, Osteoporosis, Peripheral neuropathy, GERD. Came in with pain in lower left thoracic cavity- thought fx ribs but nothing on xray. Pneumonia diagnosed 2 days after being admitted.

kmp23 said:
Hi thank you for your response, My care plan has 3 parts.

For the actual- Infection rt secretions in lower left lobe evidenced by crackles.

Infection is not a nursing diagnosis, it's a medical diagnosis, so you cannot use it. Even if you could, secretions and crackles may not be evidence of infection. But moving away from "Infection" as a nursing diagnosis, let's look and see what you might consider.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students.

There is a "Risk for infection" nursing diagnosis. Let's see if it applies to your patient, which I can't tell you because you haven't given me any evidence for her risk factors. They include chronic disease, deficient knowledge to avoid exposure to pathogens, inadequate primary defenses (there is a very long list here, which I will not quote to you but you will need to see), inadequate secondary defenses (ditto), inadequate vaccination, increased environmental exposure to pathogens, invasive procedures, and malnutrition.

Once again, you cannot make this up as you go along. You must use NANDA-I 2012 - 2014 nursing diagnoses and defining characteristics.

kmp23 said:

Risk- risk for falls rt impaired physical mobility evidenced by pain in lower left thoracic cavity and peripheral neuropathy.

Let's look at this with the translation of nursing diagnosis. What you have said here is, your patient is at risk for falls due to impaired physical mobility. This may be true. However, this is not evidenced by pain. You could say, for example, that her impaired physical mobility is due to pain and peripheral neuropathy. However, those are not evidence of her impaired physical mobility. Once again, risk diagnoses do not have evidence. They have risk factors.

kmp23 said:

Health Promotion- Readiness for enhanced nutrition rt desire to improve evidenced by low calorie intake but expresses willingness to enhance nutrition.

I think you're getting a message here. Readiness for enhanced nutrition is, in fact, a real nursing diagnosis. Matter fact, it's on page 176 of your NANDA-I, which you should have in your hands any day now. 🙂 As a bonus, expressing willingness to enhance nutrition is a defining characteristic for this diagnosis. :smokin: You would, therefore, have to give evidence that your patient does, in fact, wish to enhance her nutrition. However, you should know, that the definition of readiness for enhanced nutrition is, "a pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened." Does this meet your assessment of this patient? You say she has a low calorie intake, which would argue against it.

Therefore, you might also want to look at, "risk for imbalanced nutrition: less than body requirements." This is defined as intake of nutrients insufficient to meet metabolic needs, and has a very long list of defining characteristics. Its related factors are biological, inability to absorb nutrients, and others which might apply to your patient.

kmp23 said:

This is what I had at first but my patient did mention stuff about the pneumococcal vaccine. Especially since she has a history of pneumonia. But I was having difficulty figuring out what to write/goals/interventions.

For risk diagnoses, your goals and interventions are aimed at reducing or eliminating the factors which put the patient at risk. for a great resource for validated nursing interventions,I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on page 475, you will find "tissue perfusion, peripheral, ineffective." This is followed by the lay definition of what circulation status is, major interventions for arterial insufficiency and venous insufficiency, and a long list of suggested and optional interventions from which to choose. It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon.The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon.

It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Thank you very much for your help. I made some changes-

Activity intolerance r/t immobility evidenced by exertional dyspnea.

Risk for falls r/t impaired physical mobility due to pain and peripheral neuropathy.

Readiness for enhanced nutrition r/t a desire to improve wellness evidenced by expresses willingness to enhance nutrition.

or

Readiness for enhanced self health management r/t a desire to improve pulmonary function evidenced by desire to manage the illness

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

kmp23 said:
Patient is 78 History- COPD, HTN, Osteoporosis, Peripheral neuropathy, GERD. Came in with pain in lower left thoracic cavity- thought fx ribs but nothing on xray. Pneumonia diagnosed 2 days after being admitted.

Again you gave me medical diagnosis information. There is no data here so I can help you.

What did your physical assessment tell you? what are the labs? What are their vitals? What are their lung sounds? What meds are they on?

What semester are you so I can better help. What care plan/nursing diagnosis book are you using? Do you have one?

A nursing diagnosis is best said by GrnTea....

Quote
A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

("Related to" means "caused by," not something else.)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor.

Looking at activity intolerance.....

Ackley: Nursing Diagnosis Handbook, 10th Edition

NANDA-I Definition

Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Defining Characteristics: Abnormal blood pressure response to activity; abnormal heart rate response to activity; EKG changes reflecting arrhythmias; EKG changes reflecting ischemia; exertional discomfort; exertional dyspnea; verbal report of fatigue; verbal report of weakness

Related Factors (r/t): Bed rest; generalized weakness; imbalance between oxygen supply/demand; immobility; sedentary lifestyle

Your ND: Activity intolerance r/t immobility evidenced by exertional dyspnea.

Is the exertional dyspnea due to immobility or due to the pneumonia

Are they immobile because of the pneumonia, weakness and exersional dyspnea?

What evidence do you have to support this? What was their respiratory rate? What is the O2 sat? What did your patient verbally say? What are their lung sounds?

My patient has activity intolerance R/T pneumonia, C/O fatigue (give quote) and SOB as evidenced by exersional dyspnea, increased respiratory rate of___ and O2 sat of___ with ambulation.

Does this make sense?

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.

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 is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Now......Tell me about your patient.......What do they need? What do they c/o? What is your assessment? What is your patient saying? 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.

Patients vitals- 119/60 hr-74 o2 stat- 93 on room air, rr-18 at resting, temp 36.7

Crackles in lower left lobe

Nonpitting edema bilaterally in lower extremities and unilateral left upper extremities

Pain- 5/10 radiating from posterior chest to anterior (left side near lung)- comes and goes with movement

-patient states "throbbing, and it feels like someone is nagging me all the time."

Aox3

cough- non productive but causes sob (has asthma as well)

Braden- At risk for pressure ulcers- kyphosis keep an eye 16

Hendricks- High risk for fall 6

Katz- Patient is independent 5 (needs help getting up)

Uses cane to steady self when ambulating; good ROM in upper and lower extremities

hx of pneumonia- has the influenza shot but not pneumococcal

Sorry running to class. If I have time today Ill write more but thanks for all the help guys!

kmp23 said:
Thank you very much for your help. I made some changes-

Activity intolerance r/t immobility evidenced by exertional dyspnea.

Risk for falls r/t impaired physical mobility due to pain and peripheral neuropathy.

Readiness for enhanced nutrition r/t a desire to improve wellness evidenced by expresses willingness to enhance nutrition.

or

Readiness for enhanced self health management r/t a desire to improve pulmonary function evidenced by desire to manage the illness

Better. I am assuming that your actual patient actually gives you these assessment data with which to work. 🙂

HOWEVER,I can tell you don't have the book yet. "Readiness for enhanced self-health management" (page 164) does not have related-to (causative) factors, so you can't say it's related to a desire to improve pulmonary function. It has defining characteristics, of which "expresses desire to manage the illness (e.g., (which means, "for example") treatment, prevention of sequelae) is one. So you say, "readiness for .... as evidenced by expressed desire to manage the illness by improving pulmonary function."

GrnTea, wish I had found you and this site when I was struggling to learn how to write these things! You sure make it easier to understand than my instructors ever did :) Thank you

Thanks for the kind words. All people need is the book (NANDA-I 2012-2014) and some decent guidance on how to think about these as nursing (as opposed to medical), and then, often, the light dawns. 🙂 It's really too bad that more faculty don't have as good a grasp of this as they could, because they're the ones who should be teaching it. But hey. 🙂