First Care Plan....help!

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I am a first semester student and had my first patient. She has a diagnosis of cirrhosis, profound anemia. Her chief complaint in the ER was fatigue and lethargy. She is from Mexico and came here a week ago. Don't have past history, so all I know is that they told her in Mexico that she had anemia and cirrhosis. And she did not speak any English. Looking thru the chart I was overwhelmed and just don't know where to begin. My instructor suggested that I begin with the cirrhosis and the anemia and all that will come in. We had to make one nursing diagnosis before we saw the patient with three interventions. I went with fatigue. Anyway, I just don't know where to go from here. What do I look at? I know, not the medical diagnosis, but what the patient presents with, right? She also has bilateral pneumonia and the results of a bone marrow bx were pending. Any input is appreciated.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

hi, nancy06, fellow californian! you're stuck. let me help you get going with what your instructor advised you to do because what she told you was correct. she just didn't elaborate.

care planning is problem solving. you have to figure out what the patient's problems are. to do this, nursing gives you a tool. it's called the nursing process. the nursing process is like a swiss army knife and you can use it to help you solve a lot of situations that come up, even in your private life! but for care planning, this is how it works for you. . .it has five steps:

  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)
  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)

when your instructor told you to "begin with the cirrhosis and the anemia and all that will come in" what she was talking about was completing your assessment activities as part of step 1 of the nursing process. during step 1 assessment you want to:

  • do a physical assessment of the patient
  • assess the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease and/or medical condition(s) that they have
  • collect data from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians)
  • look up the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes finding information about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications.

when you were in the clinical area you had the opportunity to do the physical and adl assessments and go through the patient's medical record and take down information. now, you need to complete your search for data. this patient had medical diagnoses of cirrhosis, anemia (you are going to find that the anemia goes along with the cirrhosis) and pneumonia. now, if you'll just glance for a moment at step 2 of the nursing process you'll see that what you are ultimately after is symptoms. what do you know about medical diseases? they have a set of specific symptoms. did you happen to notice any of them when you did your physical assessment of the patient? when you assessed her adls? when you got information from her chart? well, here's how you're going to double-check yourself and learn from any errors your might have made. . .you are going to

  • look up the pathophysiology and signs/symptoms of
    • cirrhosis
    • anemia
    • pneumonia

you need the pathophysiology to help explain why things are occurring. many of the related factors (etiologies) of the physiological nursing diagnoses require you to know the underlying pathophysiology that is going on with the disease process. and, many of the same signs and symptoms of the medical diseases are the same defining characteristics of the nursing diagnoses. defining characteristics is the nanda language for symptoms. they are the nursing version of symptoms. defining characteristics are the evidence proving that a nursing problem exists. in fact, you already know of two symptoms that the patient has: fatigue and lethargy. now to help you complete the picture (and your education about cirrhosis, anemia and pneumonia), you are going to look up the symptoms of cirrhosis, anemia and pneumonia as well.

the symptoms of cirrhosis include such things as:

  • telangiectasis on the face
  • spider angiomas on the skin of the body
  • distended abdominal blood vessels that you can see visually
  • ascites
  • menstrual irregularities
  • reddened palms
  • clubbing of the fingers
  • lower leg and foot edema
  • bruising
  • anemia
    • tachycardia
    • dizziness
    • dyspnea
    • enlarged liver and spleen
    • weakness
    • fatigue

    [*]jaundice

    [*]you can palpate an enlarged, firm liver

    [*]enlarged spleen

    [*]asterixis (abnormal muscle tremor with jerky movements of the hands), also called liver flap or liver tremor

    [*]slurred speech

    [*]paranoia

    [*]hallucinations

as you can see, anemia is considered to be a symptom of cirrhosis. when you read about the pathophysiology of cirrhosis you will find out why. i suspect that the bone marrow biopsy was done to look for a blood disorder because they may not be certain that the cirrhosis is totally responsible for the anemia. just my :twocents:. you want to also know the complications of a bone marrow biopsy for care planning: puncture of a major blood vessel, infection, pneumothorax, hematoma and bleeding at the puncture site.

you do the same for pneumonia:

  • fever
  • productive cough with foul smelling sputum
  • dyspnea
  • tachypnea
  • tachycardia
  • rales
  • diminished breath sounds
  • bronchial breath sounds
  • dullness to percussion
  • tactile fremitus
  • egophony

your patient's medications should also be a hint as to what some of her symptoms were because physicians treat the symptoms the patient has and medications are a treatment.

there is a listing of websites on this sticky thread where you can find disease information if you can't find it in your textbooks:

for care planning you also want to look up the complications of these diseases and medical conditions because they do affect the care you provide.

once you have done all this reading and listing, you might have shaken out a few symptoms, oops, we nurses have to call them defining characteristics if we're care planning using nanda rules, that you did see, but missed. write them down now. you're going to need them in order to move on to step 2 of the nursing process here.

step 2 is the determination of the patient's problem(s)/nursing diagnosis. from all those symptoms (defining characteristics) you need to make a list. this is all the abnormal assessment data that your patient is exhibiting. normal, healthy people don't have these things, do they? these are the bits of evidence that are the foundation of this patient's nursing problems. now, you have to be like a detective and figure out what the crime is that was committed, i.e., the nursing diagnosis. every nursing diagnosis has a set of defining characteristics (signs and symptoms). what you need to do is match your patient's defining characteristics to nursing diagnoses that fit with her situation. i have to warn you not to go strictly by the diagnosis, which is merely a shorthand label, and the list of defining characteristics. you also need to read the definition of a nursing diagnosis before using it. the definition is a more complete description of the nursing problem. you will need a nursing diagnosis reference of some sort to do this. there are a number of ways to acquire this information.

the defining characteristic (symptom) of fatigue appears in several nursing diagnoses, however, it will most likely only apply to your patient for one of them. you can use fatigue r/t anemia and liver disease aeb lethargy. here are the nursing diagnosis pages from the two websites posted above for this diagnosis, there are suggestions for outcomes and interventions on them:

i'm basing that diagnosis on the information you posted. i worked med/surg for many years and saw a lot of this type of patient you are talking about and there may be a lot that either you missed or that the doctor just didn't know about her at the time you had her as a patient. our cirrhotic patients had distended bellies, were jaundiced, had urine the color of dark tea, were usually alcoholics, were in various states of confusion and azotemia, or were bleeding from any boo-boos with platelet counts so low that any bump was a reason for a bruise or a hemorrhage from an open wound.

now, once you choose your nursing diagnoses based upon the evidence you have to support them, you move to the third step of the nursing process which is planning--writing measurable goals/outcomes and nursing interventions. all of those are based upon the defining characteristics (symptoms) or evidence that you have that supports the diagnosis. goals and outcomes are aimed at reversing the related factors (etiologies, causes) of the problems as well as the symptoms. nursing interventions are aimed at treating and relieving the defining characteristics (symptoms) in order to achieve the goals and outcomes. it all ties up in a nice little package of rationale thinking.

all that comes from knowing these things about this patient:

  • she has
    • cirrhosis
    • anemia
    • pneumonia
    • fatigue
    • lethargy

at the bottom of my post is a link for a critical thinking flow sheet for nursing students. you can open and download it. it is a form to help you organize information you need to know as you study diseases and conditions as you are going through nursing school. you may or may not find it helpful.

most of what i posted above and more is posted on this sticky thread in the general nursing student discussion forum:

good luck! let me know if you need more help with this or if i didn't explain something clearly. i worked on an alcohol detox unit and had so many patients with cirrhosis that i could write this care plan blindfolded. not that i am bragging, but you need to learn how to do this. cirrhosis is one of the big reasons for gi admissions so i doubt that this is the last of this type of patient that you will see

by the way, a language barrier, if her english was not very good, is a defining characteristic of impaired verbal communication. i used to work in el centro. we had mexicans coming across the border for medical care all the time. you wouldn't believe some of the horrors we saw.

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here's a site that helps me out a lot with my care plans. i am in nursing school also and graduate in december. i am not a fan of care plans!

[color=#003399]http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

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