Nursing care plan

Hon,

Go read your Medical-Surgical Nursing books. The answers are all there. Focus on Respiratory problems. Spoonfeeding is not encouraged in Nursing.

I would recommend getting a nursing care plan workbook. I had trouble at the beginning of nursing school and after Ipurchased a NCP workbook, my NCP's really improved. It has tons of examples including interventions and PC's. I bought this one: Nursing Care Plans: Nursing Diagnosis and Intervention, 5th Edition

Authors: Meg Gulanick & Judith L. Myers

But there are several options out there, just find one that works best for you!

Michelle Willerford

Elsevier Student Ambassador

try impaired gas exchange.

a care plan is about determining the nursing problems that a patient has and then developing strategies to do something about them. the problem here is that pneumonia and pleural effusion are medical problems which a doctor has diagnosed and will be treating. a thoracentesis is a medical treatment that a physician does to relieve accumulations of air or fluid from someone's pleural space (the pleural effusion). what we nurses treat are patient's responses to medical disease/conditions. we also assist physicians in carrying out some of their treatments. there are also things we can do independently of what the doctors do.

care planning is accomplished by using the nursing process which is our tool for problem solving. begin with step #1 which is assessment and work through each step in sequence. assessment consists of:

• a health history (review of systems) - pneumonia and pleural effusion. do you know anything more about how this pneumonia came about? any other medical history that is important to know?
  
• performing a physical exam - physical assessment is crucial to your care plan. with a patient who has pneumonia and a pleural effusion you should assess their respiratory system (breathing, lung sounds, any cough, sputum production). [assessing the respiratory system: http://www.merck.com/mmpe/sec05/ch045/ch045a.html] what other data about the patient do you have? can they ambulate? do a head-to-toe assessment and write down your findings.
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - assessing and assisting patients with their adls is what we nurses do. a patient with pneumonia may have problems performing activities.
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - the pathophysiology of the kind of pneumonia the patient has and how they came to get it is necessary to the formation of the etiologies for the nursing diagnostic statements. if you do not have a pathophysiology book, some of that information can be found here:
  
  • http://www.merck.com/mmpe/sec05/ch052/ch052a.html - the pneumonias
    
  • http://www.merck.com/mmpe/sec05/ch060/ch060d.html - pleural effusion
    
  • http://emedicine.medscape.com/article/300157-overview - bacterial pneumonia
    
  • http://emedicine.medscape.com/article/300455-overview - viral pneumonia
    
  • http://emedicine.medscape.com/article/299959-overview - pleural effusion
    
  • https://allnurses.com/forums/f205/pulmonary-tuberculosis-pneumonia-pathophysio-273191.html - the pathophysiology of pneumonia
    

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - thoracentesis is a medical treatment. complications to monitor for include a pneumothorax, a superimposed infection, pain, subcutaneous hematoma, laceration of the intercostal artery and reexpansion pulmonary edema.

  • http://www.merck.com/mmpe/sec05/ch047/ch047i.html - thoracentesis
    

collect as much of this data as you can, even if this is a case study or the patient is not a real patient. nursing problems are based upon abnormal data. the next step in the nursing process is to make a list of all the data you have collected that is abnormal. this data are cues or signs and symptoms of actual nursing diagnoses (nursing problems) that the patient has. the trick is determining which nursing diagnoses they are. for nursing diagnosing, the symptoms can also be the same ones the doctors focus on as well as include the patient's response to their diseases and conditions along with their ability to perform their adls. every nursing diagnosis has a list of signs and symptoms (nanda calls them defining characteristics). before you assign any nursing diagnosis to a patient you should check to make sure that they have one of more of the symptoms listed under a nursing diagnosis. you should also double check the definition of the nursing diagnosis to make sure it is indeed the correct problem that the patient has. these two websites have that information for about 80 of the most commonly used nursing diagnoses:

• http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
  
• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
  

once you have diagnosed your patient, the goals of nursing treatment are the predicted results of the nursing interventions you will be ordering for the specific nursing problem. nursing interventions specifically target the signs and symptoms that are the reason the nursing problem exists. everything is based upon what you found during the assessment of the patient--the first thing that was done as part of the care plan process.

you can see more examples of how care plan construction and nursing diagnosis determination are done on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. please assemble assessment data for this patient. in order to help you further, i have to see that specific information.

thanks for taking the time to explain that! the websites were helpful!

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