Published Oct 26, 2008
TIREDSTUDENTRN
2 Posts
HELP PLEASE!
I'm doing a care plan on a patient with atrial fibrillation and osteomyelitis. I have to put these dx's in order of priority. Assessment is as follows... B/P: 122/70, temp: 98.8. Neuro: Neuropathy in fingers. cardiovascular: Weak peripheral pulses, cool pale extremities, PICC line. Pain: occasional reports of pain at PICC line and finger. No genitourinary, psychosocial, GI probs. Musculoskeletal: osteomyelitis. Integumentary: PICC line in place.
Daytonite, BSN, RN
1 Article; 14,604 Posts
Where are your nursing diagnoses?
I'm toying with:
Decreased cardiac output r/t alteration in preload, Ineffective peripheral tissue perfusion r/t mechanical reduction of venous and / or arterial blood flow, Impaired tissue integrity r/t, Risk for infection. What do you think? I wanted to do a PC: infective emboli or DVT, but I cannot remember how to put it on the care plan (how to write it up/ if I need a r/t or aeb, etc.) I'm going crazy here! Any tips would be greatly appreciated!
use the nursing process to help develop you care plan in the the sequence that the steps occur.
[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
[*]planning (write measurable goals/outcomes and nursing interventions)
[*]interventions are of four types
[*]care/perform/provide/assist (performing actual patient care)
[*]teach/educate/instruct/supervise (educating patient or caregiver)
[*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
[*]implementation (initiate the care plan)
[*]evaluation (determine if goals/outcomes have been met)
i cannot tell how you arrived at your choice of nursing diagnoses. every nursing diagnosis has a set of defining characteristics. i cannot tell how you utilized your patient's symptoms in arriving at the 4 diagnoses that you came up with since i only picked up on 3 symptoms that you posted. this is how i used the nursing process and the information you supplied to come up with nursing diagnoses for this patient:
step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
your diagnostic suggestions are:
TexasCowgirl24
35 Posts
Always start with your abcs. A-fib, maybe decreased cardiac output r/t altered electrical conduction? A pain dx is always an important one for me. Without a more detailed assessment, any more dx I could come up with would just be a guess.
Good luck!