Desperately need help with careplans - page 4

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  1. by   Daytonite
    Quote from audy_lagz
    39 ye31 yr old man visits his hc provider with complain a burning epigastric injury occuring 2 hours after he eats. he consistently feels bloated and obtains little or no relief from otc antacids. his last health history- cigarette smoking, stressful job, chronic use of nsaid and diagnosed peptic ulcer.
    here is information on peptic ulcer disease, etiology, symptoms, how it is diagnosed and managed medically.

    your main problems are most likely going to be what i have listed below and bold-faced. feel free to add other symptoms i might not have considered. i have not included any of the medical tests that might be ordered or the medications or treatments the doctor might order. i'll let you do that since it may be different from what is done here in the u.s. i didn't address anything related to helicobactor pylori testing or treatment which i'm sure would be undertaken. you'll want to address the side effects or special needs of the patient receiving medications and treatments, so don't forget to include those.

    mid-epigastric pain, deep recurring ache unelieved with food or antacids and aggravated by general irritants (below)
    nocturnal pain is present and aggravated by food
    weight loss
    nausea or vomiting

    in developing your careplan, what you are going to do is address each of these symptoms that are listed and have nursing interventions for each of them. now, here in the u.s., we make a distinction between actions that a nurse can do independently from the doctor and those that depend on a doctor's order (we call those collaborative interventions). if you have a careplan book you can find these interventions listed under these symptoms very easily, or in a nursing textbook. you can also find some of them listed at either of these care plan generator sites by looking under the nursing diagnoses of acute pain, nausea, deficient fluids volume, imbalanced nutrition: - care plan generator for the gulanick books - nursing care plan generator

    if you need further help, post another question to this thread.
    Last edit by Daytonite on Jun 6, '09
  2. by   kidwellpm
    In my peds class I was assigned a care plan on ethylene glycol poisoning (antifreeze). So far I have been unable to find any nursing interventions for this. Please help if you know a website or any interventions. Most seem to deal with lead poisoning that I have found, even in my peds book. Thank you so much.
    Last edit by suebird3 on Aug 31, '06
  3. by   Daytonite
    hi, kidwellpm!

    first of all, with any care plan you must address and follow the nursing process. always, always, always! the first step is to collect your data. what data do you have? is this a real patient? or, is this a case study where you have to put together the likely signs and symptoms of ethylene glycol poisoning?

    here are some websites that might help:

    there are, in general, three stages to ethylene glycol poisoning (1) neurological stage, (2) cardiopulmonary stage, and (3) renal stage. these are the symptoms that appear with these stages:

    (1) neurological state
    confusion, appearance of being intoxicated
    slurred speech

    (2) cardiopulmonary stage
    irregularities in heartbeat and breathing (due to building up of 0xalic acid)
    dyspnea (respiratory distress with hyperventilation) (these are symptoms of metabolic acidosis) (may require intubation and ventilation for airway protection and respiratory support)
    (will need sodium bicarb iv to overcome the metabolic acidosis)

    (3) renal stage
    oliguria or anuria due to acute renal failure
    the oxalic acid forms a precipitate (calcium oxalate) with calcium in the kidneys
    muscle tetany or seizures due to hypocalcemia

    untreated, the patient proceeds to develop:

    treatment is aimed at (1) correcting the metabolic acidosis, (2) preventing the ethylene glycol from metabolizing into toxic metabolites and (3) removing it and any metabolites that have formed from the system. the patient is going to die if not treated within 24 to 36 hours.

    second order of business. . .after collecting your data, you need to assemble it and group it into symptoms that will fit into nursing diagnostic categories. each of the nanda nursing diagnoses has symptoms that fit it. some ideas for nursing diagnoses you could use are (and this list is not inclusive, there are more you could use):
    • acute confusion r/t ethylene glycol ingestion aeb confusion, slurred speech, and hallucinations
    • nausea r/t ethylene glycol ingestion aeb vomiting
    • ineffective breathing pattern r/t hyperventilation aeb dyspnea
    • ineffective tissue perfusion r/t reduction of arterial and venous blood flow aeb dysrhythmias, abnormal abgs, oliguria and anuria
    third. . .once you have all your data and have decided on the nursing diagnoses to use, the nursing interventions are not that hard to figure out. they are geared to the symptoms (the aebs) that support each of your nursing diagnoses. for example, you would list nursing interventions for vomiting under the diagnosis for nausea r/t ethylene glycol ingestion aeb vomiting. you would find these in your nursing textbooks, such as having the patient avoid sudden movements, keeping a emesis basin near the patient, giving oral care after each episode of vomiting, offering clear fluids when vomiting under control, etc. for pediatric patients clear fluids would be things like popsicles or pedialyte.

    hope this has given you some direction with this assignment.
    Last edit by Daytonite on Jun 6, '09
  4. by   Daytonite
    a nursing diagnosis is not much different from a medical diagnosis. each has signs and symptoms. medical diagnoses are easier for you to understand because you've heard of them forever. you know that a sore throat and a runny nose is a cold. who doesn't? but, what is new and different to you is to be told that dyspnea, an ineffective cough, sputum production and restlessness are symptoms of a nursing diagnosis nanda calls ineffective airway clearance! you will learn these nursing diagnoses by either sitting down and reading each one and memorizing it's signs and symptoms , or through the various care plans you will write over your school and job career . learning new concepts like this is never a lot of fun and often takes time and a lot of effort. it will take many, many weeks and perhaps months before you begin to feel like you have a good grasp of what is going on with the nanda diagnoses. for the present, follow the guidelines your instructors suggest and those in any of the care plan books you might be using for reference and trust that they are giving you proper direction. there are always people here on the forum to help out as well.
  5. by   VickyRN
    Last edit by VickyRN on Jul 23, '07
  6. by   VickyRN
    a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and/or potential health problems or life processes. a medical diagnosis, on the other hand, is the identification of a disease based on its signs and symptoms.

    the professional practice of nursing is the diagnosing and treatment of these basic human responses. nurses need a common language to describe the human responses of individuals, families, and communities to health threats. nanda strives to classify in a scientific manner these basic human responses.

    nursing diagnoses are classified under the concepts of ingestion, digestion, absorption, metabolism, urinary/gastrointestinal elimination, sleep/rest, activity/exercises, energy balance, sexuality, post trauma responses, comfort, and growth and development.

    identification of human responses to health problems and life processes is the basis for the nurses' decisions on how to help people. with nursing diagnoses, emphasis is placed upon achievement of the client's maximum health potential. the nurse gathers the assessment data and from this data, identifies high-priority nursing diagnoses. the nursing diagnoses then provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

    the patient (not the nurse) is central to the nursing process. the nursing process involves looking at the whole patient at all times. it personalizes the patient. nursing care needs to be directed at all times for improving outcomes for the patient.

    in order to tailor the nursing process to the patient, you need to identify the patient's problems related to the objective and subjective assessment data. then you need to formulate a nursing diagnosis for each of these problems. you will also prioritize the problems in formulating your plan and goals (according to the abc's and maslow's hierarchy of needs).

    nursing diagnoses are written in "pes" format:

    • "p" stands for problem
    • "e "stands for etiology or cause of problem
    • "s "stands signs and symptoms of problem
    however, if you identify a high-priority "risk for" nursing diagnosis, then you do not put the signs and symptoms (in other words, no "aeb"). how can you have evidence (signs and symptoms) for something that is only a risk?
    nursing goals are simply the antithesis of the nursing diagnostic statement with a reasonable time frame. in other words, diagnostic statements are "problems" (negative). goals are "positive" (turn the nursing diagnostic statement around). if the nursing diagnosis is "risk for infection r/t..." for instance, then the goal statement might be "client will not experience infection throughout hospital stay aeb clear lung sounds, afebrile, wbc count between 5,000 and 11,000, wound site well approximated with no purulent drainage." goal statements always begin with "the patient/ client will..." and have a specified time element.

    nursing interventions are the "meat and gravy" of the nursing process and flow from the "etiology" part of the nursing diagnostic statement. nursing interventions are either independent (such as teaching/learning or safety) or collaborative/ dependent (require a physician's order, such as administration of medications). the nurse must use his or her critical thinking skills to plan, coordinate, and implement nursing interventions, and then evaluate the effect of these interventions in achieving the desired patient goal. nursing interventions always begin with "student nurse will..." or "nurse will..." and are very specific, as well as being realistic to the client situation (not just "cookie-cutter" interventions copied from a nursing careplan book

    helpful examples of nursing interventions (in this case, related to visual disturbances) may be found at these websites:

    nursing interventions must be backed up with a scientific rationale - otherwise, this action is just your opinion and has no merit. remember, everything in nursing must be evidenced-based. provide a citation for your scientific rationale, in apa format, from a peer-reviewed source: professional journal, textbook, lecture.

    when evaluating your goals, need to state specifically: goal met, goal not met, goal partially met, or unable to evaluate goal due to time constraints. if the latter is the case (unable to evaluate goal due to time constraints), then you need to state what outcome criteria would be needed in order to state goal met. in other words, if i were present (at specified time element), i would look for the following outcome criteria in order to state, "goal met." then you list the desired outcome criteria. remember, you are evaluating the goals, not the interventions.

    so you see, it is an orderly, evidenced-based process and not that difficult with practice. nurses cannot know what interventions to select or which outcomes to project unless they have accurate representations of what patients are experiencing (using a common reference language, nanda).
    Last edit by VickyRN on Dec 26, '06
  7. by   Daytonite
    Quote from rstudentrn on 9/4/2006
    o.k here was another question that i got stumped on...

    your patient has end stage renal disease, with a 30 year hx of type 1 dm. she has a 2-cm dry, ulcerated circular area on the lateral outer aspect of her right great toe and an av fistula in the right forearm. you have adminisered her am nph insulin at 0730 and you are waiting for her dialysis treatment. at 1130 you do a fingerstick and the results are 236, according to the sliding scale you administered 10 units of regular insulin.
    which of these nursing diagnosis is a priority at this time.
    risk for infection
    altered patterns of elimination
    excess fluid volume
    deficient fluid volume
    imbalance nutrition:less than body requirements

    i choose fluid volume excess, because she is now hyperglycemic. wouldn't there be a fluid shift from intracellular to intravascular because of the high concentration of glucose in the vascular system.

    f&e confuses me...anyone have any ideas. thanks
    the answer to this is risk for infection. the patient has symptoms that fit the description for this nanda diagnosis (i.e.: inadequate primary defenses--broken skin, chronic disease). your knowledge of diabetes should also tell you that an elevated blood sugar in a diabetic is reason for concern of possible infection if the diabetes is supposed to be under control. the heart of this question is getting at the symptoms of each diagnosis. in actuality, the information given in the question only supports two of the diagnoses given: risk for infection and, surprise!, deficient fluid volume (the dry skin on her toe), and your knowledge of esrd tells you that can't be right! so, of all 6 nursing diagnoses listed, only one fits the symptoms given and can be your answer.

    do you have a care plan book that lists the diagnoses in alphabetical order as well as the symptoms (defining characteristics) that go with each? this is what you need to be looking at with each of these nursing diagnoses. like a medical diagnosis, each nursing diagnosis has specific signs and symptoms that have to be present in the patient in order to use that particular nursing diagnosis. if the symptoms aren't there, then you can't use the diagnosis. this is a concept that you must hammer in to your head about nursing diagnosis.
  8. by   krg0818
    I am having a hard time with coming up with a nursing diagnosis for anemia.......... can someone help??
  9. by   Daytonite
    hi, krg0818!

    have you read any of the previous posts in this thread? the problem i have in helping you out here is that you have listed none of your assessment data. the care plan is the written document of the nursing process. step #1 is the collection of data. that includes information you get from the patient's chart and from your own hands-on assessment and observation of the patient. you need this data in order to determine which nursing diagnoses to use. this webpage at family practice notebook lists the common signs and symptoms of general anemia to help you determine what symptoms belong to anemia. your patient may have symptoms of other problems beside anemia as well. there are links on the left side of the page to other pages of information on anemia that include the causes and more diagnostic testing and treatment if you need that information.

    step #2 of the written care plan process is to assemble, or group, the abnormal data you discovered in your data collection process into nursing diagnoses. each nanda nursing diagnosis has specific symptoms. if you have a recently published care plan book to help you, it should list these symptoms for all the various nursing diagnoses. it is for this reason that it would be hard for me to just, out of the blue, list some nursing diagnoses for you. i might miss something important that you need to address with this patient that might not necessarily be related to the anemia.

    please give me a list of the symptoms this patient has so i can begin to help you put together some nursing diagnoses.

    welcome to allnurses!
    Last edit by Daytonite on Jun 6, '09
  10. by   Daytonite
    How do you make the decision to prioritize which nursing diagnoses to place at the very top of a nursing care plan?
    The first diagnoses to go up on the top of the list are those that affect the airway, breathing or circulation (as in the heart). This is just like the ABC's of CPR. There are certain NANDA diagnoses that fit into these three categories:
    • Ineffective Airway Clearance - not having the ability to clear out mucus or other obstructions from the respiratory tract in order to maintain a patent airway
    • Decreased Cardiac Output - the heart is unable to pump out enough blood to meet the metabolic demands of the body
    • Fluid volume deficit - intravasular, interstitial and/or intracellular fluid is decreased (as in conditions like hemorrhage, severe shock, multiple organ failure)
    • Impaired Gas Exchange - oxygenation and/or carbon dioxide exchange at the alveolar-capillary membranes is damaged or deteriorated so there is excess or deficiency of either gasses in the system (patient will usually be in severe respiratory distress)
    • Ineffective tissue perfusion (must specify as to renal, cerebral, cardiopulmonary, gastrointestinal or peripheral) - tissues are failed to be nourished at the capillary level because of a decrease in oxygen
    • Impaired Spontaneous Ventilation - decreased energy resulting in the inability of the individual to maintain their breathing adequately to sustain their life
    A NOTE: Don't choose a nursing diagnosis without the patient having the signs and symptoms to support using it. See a current care plan book or NANDA's book, Nursing Diagnoses: Definition & Classification 2005-2006, for this information.

    The next in the hierarchy depends on what your nursing program has directed you to place in importance. These are three of the most popular systems:
    • Maslow's Hierarchy of Needs
    • Gordon's 11 Functional Patterns
    • Roper, Logan & Tierney Activities of Living
    Do any look familiar to you? If you have Ackley and Ladwig's Nursing Diagnosis Handbook you will find a grouping of all the nursing diagnoses under each of Maslow needs and Gordon's functional patterns at the back of the book in Appendix A & B, respectively. In the care plan books by Doenges, Moorhouse and Murr they list, on two pages toward the front of their books, all the nursing diagnoses grouped into 13 diagnostic divisions that don't resemble Maslow or Gordon at all. You always need to consider what is an immediate danger to the patient's life or limb. Maslow is very specific in listing the following in order of importance in the category of physiological needs which must be met first:
    1. oxygen
    2. food
    3. elimination
    4. temperature control
    5. sex
    6. movement
    7. rest
    8. comfort
    Safety and Security needs come next in Maslow's hierarchy and this order:
    1. safety from physiological and psychological threats
    2. protection continuity
    3. stability
    4. lack of danger
    Any nursing diagnoses that begin with the words "Risk of. . ." are considered to be anticipated problems. In other words, they are problems that do not yet exist. Of course, they are important, but for care planning purposes they are not as important as those problems that already prevail. Therefore, they are listed last. Within the group of anticipated problems you can prioritize their sequencing according to Maslow or Gordon as well.
    Hope this gives you some help and guidance. Happy care plan writing!
    Last edit by Daytonite on Sep 11, '06
  11. by   Lisa8361
    Hi all,

    I sure could use a gentle nudge in the right direction. I am trying to come up with a Nursing care plan for a patient with sepsis caused by bacterial pneumonia. Have been using Mosby's Nursing Care Plans book as a guide, but am having trouble find interventions that apply to my patient. While she is receiving antibiotics, most of her care is comfort only as she is facing end of life in the immediate future. Can only use one assessment intervention and no Risk for interventions. Any suggestions? Need five total
  12. by   slinkeecat
    what have you got so far?
    ineffective tissue perfusion: cardiopulmonary/peripheral r/t arterial or venous flow exchange problems: sepsis...
    Risk for injury: r/t sepsis resulting in mutiple organ failure , death
    ineffective protection: r/t inadequately functioning immune system
    imbalanced nutrition: less than body requirements r/t generalized weakness, anorexia

    address air way... if she is gunky:
    ineffective airway clearance: r/t poor cough, thick secretions...

    hope this helps!!!
    I remember care plans well and still hate them.
  13. by   Lisa8361
    So far I have come up with:

    Decreased Cardiac Output R/t inadequate fluid volume AEB hypotension and Decreased Urinary output (< 30 mL/hr) Not sure about the R/t, kind of winging it.


    Monitor vital signs with frequent monitoring of BP

    Monitor urine output with Foley catheter.

    Need three more therapeutic interventions? This is making my crazier than normal.