Nursing Care Plan

[mizlaura]

I have looked at a lot of the previous posting about working on care plans for class. Like many others, I am overwhelmed and confused!! I feel like my instructor isn't given us good explanation to go about creating one. But I have taken some considerations from these previous posting. However, I am stuck with some long term goals/interventions/rationale/evaluation. So here is what I have for Nursing Diagnosis: Impaired Comfort r/t lack of ease, relief, and transcedence in physical, psycho-spiritual, environmental, and sociocultural dimensions. The followings are short term goals and long terms goals that I have so far:

Short term goals: Patient will state her pain level at 1 to 2 within 20 minutes of analgesic.

Long term goals: Patient will maintain stated level of comfort during hospitalization which will be measured by:

1. Assessing client’s level of comfort on an hourly basis. Sources of assessment data to determine level of comfort can be subjective, objective, primary, or secondary.

2. Patient will be repositioned every hour. Ambulation will begin daily with a goal of 10 feet. Once goal is obtained, an additional 5 feet will be added per goal met. A review comparing the study by Chair et al found its results to be consistent with other studies that have found that backrest elevation, side lying, and early ambulation all improved comfort.

3. Patient will be educated to the use of relaxation techniques that may reduce her pain and fatigue, and enhance her personal well-being daily. In a systematic review of randomized controlled studies, it was found that relaxation training was effective for decreasing pain intensity, depression, and fatigue in clients with chronic musculoskeletal pain.

So, I was told by instructor that we need 5 long term goals and this is where I am stuck with. My Nursing Diagnosis Handbook only has a handful for this Nursing Diagnosis (Impaired Comfort). I may be wrong but correct me... I cannot use other Nursing Interventions from other Nursing Diagnosis other than the one I have, right? If anyone can also give me example on interventions/ evaluation, I would greatly appreciate it as well. My apology in advance that this is so long, and perhaps does not even make sense, but I am over my head with trying to figure out more long term goals, interventions, and evaluation!

Thanks in advance!

[Julie Reyes, DNP, RN]

Hi! Ok, so first of all, what is wrong with your patient? Can you give a brief history of the present illness?

Second - I always tell my students to consider all of the ABC's in creating your care plan first. (Like Ineffective breathing pattern; ineffective peripheral tissue perfusion, risk for decreased cardiac tissue perfusion). I would want you to consider the things that could kill your patient faster than impaired comfort.

That being said, impaired comfort is very important and should be considered for patients who are unable to relax or are restless due to whatever the cause may be. Long term goals may be achieved after interventions - like relaxation exercises, medication administration, etc.

Hope that helps a little!

[mizlaura]

Thanks Julie Reyes for responding. Here is a brief history of my patient that I am working with:

**** *****, who is hospitalized now, is a 55-year-old woman who is having a Jejunostomy tube removed and living with chronic pain related to stage IV pancreatic cancer. She was a pack a day smoker but did quit 5 months ago. She has been treated with chemotherapy with gemcitabine through an implanted port in her left upper chest following a Whipple surgery. The physician did order a nasogastric tube and she has been receiving parenteral nutrition at night due to the jejunostomy tube not functioning correctly. Upon admission she had severe abdominal pain and stated “the pain is mostly in my stomach but I hurt all over.” She is receiving Fentanyl 25mcg for her pain that she rates a 5 out of 5 and Zofran 4mg prn for nausea. Upon admission she did have a fever as well of 101.4 and oxygen saturation of 83% on room air with decreased breath sounds bilaterally noted. Her abdomen is slightly distended with no bowel sounds heard. She has a history of low neutrophil counts. Reverse isolation precautions have been instituted and lab reports are pending. She is confused, knowing where she is but unsure as to why. However, she has indicated she is aware she is dying and would like to die at home. Family has been arguing regarding if it is feasible for her to remain at home and a hospice referral has been made.

My three nursing diagnosis that I was able to come up with are:

1)Impaired gas exchange r/t ventilation perfusion imbalance and alveolar-capillary membrane changes AEB decreased bilateral breath sounds, respirations at 22 breaths per min, O₂ sats of 83%, and a weak/dry cough.

2)Risk for acute confusion r/t electrolyte imbalance, malnutrition, pain.

3)Impaired comfort r/t generalized pain and illness AEB respiratory rate or 22 breaths per minute, increased temperature of 101.4^o F, decreased blood pressure of 92/58, rates pain 5/5.

[mizlaura]

I guess what I am trying to say is ... can I seek other interventions/rationales from other nursing diagnosis as long as it relates to what I am working with? I am having a hard time trying to find more long term goals along with finding the right interventions and rationales to back it up.

And do I need to write evaluation for each goals as well??

[Julie Reyes, DNP, RN]

I will retread this tomorrow and respond- but real quick edit your reply and take out the patient name!

[mizlaura]

Sounds good. This is a fake patient, but will go remove it. Thanks!

[mizlaura]

Oh my! I can not even edit the post to remove the name...

[tnbutterfly - Mary, BSN]

I removed the name.

[Esme12, ASN, BSN, RN]

Yes you can use other interventions from other diagnosis if they apply. I would also consider using chronic pain as the nursing diagnosis and even acute pain even if from an old issue.

I would reconsider risk of confusion as she is presently confused.

What care plan resource are you using? What semester are you?

Care plans are all about the patient assessment. What the patient needs right now. Where they in the hospital? Are they living in long term care? Where did you meet the patient?

If this is an actual patient....what is your assessment? What were the vital signs? What did the patient complain of? Are the ambulatory? How are they at performing their ADL's?

Here is my normal speech.....You have fallen into the trick bag that many nursing students do....picking a diagnosis then trying to fit the patient into that diagnosis.

All care plans are based off of the patient assessment... Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? 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.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

Care plan reality: 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.

A nursing diagnosis statement sounds like this.....from our GrnTea

Quote

"I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

[Esme12, ASN, BSN, RN]

mizlaura said:

Thanks Julie Reyes for responding. Here is a brief history of my patient that I am working with:

**** *****, who is hospitalized now, is a 55-year-old woman who is having a Jejunostomy tube removed and living with chronic pain related to stage IV pancreatic cancer. She was a pack a day smoker but did quit 5 months ago. She has been treated with chemotherapy with gemcitabine through an implanted port in her left upper chest following a Whipple surgery. The physician did order a nasogastric tube and she has been receiving parenteral nutrition at night due to the jejunostomy tube not functioning correctly. Upon admission she had severe abdominal pain and stated “the pain is mostly in my stomach but I hurt all over.” She is receiving Fentanyl 25mcg for her pain that she rates a 5 out of 5 and Zofran 4mg prn for nausea. Upon admission she did have a fever as well of 101.4 and oxygen saturation of 83% on room air with decreased breath sounds bilaterally noted. Her abdomen is slightly distended with no bowel sounds heard. She has a history of low neutrophil counts. Reverse isolation precautions have been instituted and lab reports are pending. She is confused, knowing where she is but unsure as to why. However, she has indicated she is aware she is dying and would like to die at home. Family has been arguing regarding if it is feasible for her to remain at home and a hospice referral has been made.

My three nursing diagnosis that I was able to come up with are:

1)Impaired gas exchange r/t ventilation perfusion imbalance and alveolar-capillary membrane changes AEB decreased bilateral breath sounds, respirations at 22 breaths per min, O₂ sats of 83%, and a weak/dry cough.

2)Risk for acute confusion r/t electrolyte imbalance, malnutrition, pain.

3)Impaired comfort r/t generalized pain and illness AEB respiratory rate or 22 breaths per minute, increased temperature of 101.4^o F, decreased blood pressure of 92/58, rates pain 5/5.

I agree with impaired gas exchange. She is already confused so she is no longer at risk for that diagnosis. Impaired comfort is okay....but chronic/acute pain would be better suited for this patient. You should also think about her end of life issues and family dynamics as a part of your diagnosis...how many do you need to have? Are they to be according to Maslow's?

[Julie Reyes, DNP, RN]

mizlaura said:

Sounds good. This is a fake patient, but will go remove it. Thanks!

I am glad you said it was a fake patient! I almost had a heart attack when I first read it! haha!

I think your answer was given really well by Esme12!

Let us know if you have any other questions!

[mizlaura]

Thank you.