Nursing Care Plan Help

Nursing Students Student Assist


Hey guys! So I'm a 1st year nursing student & my class just recently started to do Care Plans. Unfortunately, I'm just not understanding how to do it. My professor just basically touched base on it & by the end of class, EVERYONE in class was equally confused. I understand the Nursing Assessment but I can't seem to apply this knowledge to make an accurate care plan. Please help! I have to at least make 4 Nursing Diagnoses as well as complete the care plan but I'm not sure if I'm doing this right. So far I have "Constipation R/T poor eating habits a.e.b. anorexia." Am on the right track?

I.J. is a 78-year-old woman admitted to the hospital with a Dx of heart failure. I.J. lives by herself in her own home. Her Sx are severe fatigue, poor memory, & concentration. Her hair looks dull; she is pale & has anorexia & constipation. She is also very sensitive to the cold. She has 2+ edema in her feet & legs. Her heart sounds are distant. Her lung sounds are diminished but clear. Her BP is 110/60, heart rate 56, respiratory rate of 20. She is 5'3" & weighs 142 lbs. Her daughter states that Mrs. I.J. weighed 157 lbs at the physician's office 6 months ago & that she has eaten very little for several weeks. Mrs. I.J. smoked 20 years ago. Past Hx included CVS 10 years ago with no deficits noted.

In the hospital:

Code status - limited

Diet - Cardiac

Activity - OOB to chair 3x / day, BRP


Lasix 40mg PO daily

K-Dur 20 mEq PO daily

Aricept 5 mg PO HS

Lopressor/HTC 50/25 mg PO daily

Hydromorphone hydrochloride 1 mg IV q 4 hours PRN

Coumadin 2 mg PO daily

Megace 4 mg PO daily

Lab results:

WBC - 9.8

RBC - 3.57

Hgb - 10.0

Hct - 29

Platelets - 127

Potassium - 3.5

Sodium - 135

INR - 2.5

Specializes in ED.

First of all, I don't think "poor eating habits" would be correct.

I also think you need to prioritize your diagnoses whatever they may be.

Most nursing books have at least some care plan examples or at least some nursing diagnoses in there somewhere.

Take a closer look at some of the lab values, the subjective and objective data and go from there.


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