Nursing care plan....help

[mevans40]

Hello everyone....I am in need of some desperate help with a nursing care plan and I have no idea where to start. This is my very first care plan and I need assistance. It was not explained well at all. Someone advised this website to me and they came out with an "A" on their nursing care plan. They were in the same situation I was in....HELP!!!!

My pt. 6 yr. old male

admitting dx: HB-SS Disease w/crisis

Complaint: back pain and leg pain R/T Diagnosis of Sickle Cell Anemia

He has had appendix and gall bladder removed

He was also on incentive spirometer.

He wouldn't urinate until after I left.

Very withdrawn...only to nurses, not parents.

Wouldn't eat or hardly drink.

Had IV with Vanco 300 mg/100NSCC Q 24HRS

I have to have (4) nursing problems thay must be prioritized and include subjective and objective data as well as a correctly stated current (NANDA approved) nursing diagnosis. The four problems must include (1) physical, (2) psychosocial, (3) teaching and (4) a potential problem or a high-risk problem. I was only with this pt. for 1 day and then he was discharged. I need dx., pt. goals, interventions, implementation. HELP!!!! I need to know how to organize.

[TRR8021]

Hi, I don't have a nursing Dx book in front of me but off the top of my head I'd say:

1.) Acute pain; subjective will be whatever the pt says, my back hurts, my legs hurt, whatever. Objective would be vital signs, is the pt grimacing, curled up in a ball? etc. It also seems like he has deficient fluid volume and imbalanced nutrition less than body requires. Look at his I&O's and whatever you observed during your physical assessment for objective data.

2.) Maybe ineffective coping since he's withdrawn or impaired social interaction since he's a 6 year old kid in the hospital and is most likely chronically sick with sickle cell. You can look that up in the chart if you didn't ask the parents about it.

3.)You need a Dx related to teaching? I'm not sure about that one, but you could teach him and his parents about signs of crisis or preventing another crisis maybe.

4.) I'd say his high risk problem is ineffective tissue perfusion r/t sickle cell disease.

Also, look in your care plan book. It outlines the goals, interventions, and evaluations, but of course, you have to tailor it specifically to your patient.

Hope that gets the ball rolling for you!!

[kcrewfive]

Wow, that's off the top of your head? That is great! I still look in my RN DX book.

[TRR8021]

Yeah, I use the book too but some Dx come up over and over and I remember the ones I use a lot lol.

[mevans40]

Thank you so much!!!! I am so grateful for this. If you have any more suggestions for the the 4 nursing problems that I have...I would really appreciate it. I am more than thankful.