HELP!!-- Care plan first one for med-surg

  1. I am in LPN school. This is my first med-surg care plan. I need help coming up with my 10 nursing diagnoses for this lady. She is an 87 yr old who fell and fractured her right hip and right humerus. She also has HTN, COPD, and Diabetes type 2. Her WBC is 4.5 (L) RBC 2.87 (L) HGB 9.7 (L) HCT 28.6 (L) platelets 93 (L) BUN 21 (H) and glucose 155 (H). If any one could help me i would appreciate it. I already have a few such as impaired physical mobility, activity intolerance, pain, risk for falls, and risk for infection. Thanks!!
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    About mfatony

    Joined: Sep '09; Posts: 14


  3. by   Stearnsy
    Here's a good one for COPD -- impaired gas exchange

    And platelets 93k? Ineffective protection or risk for injury R/T decreased clotting time
  4. by   Daytonite
    a care plan is about determining the person's nursing problems. nursing problems develop as the patient responds to their medical problems and living situation. most of what you told us is all about her medical problems. every medical diagnosis comes with signs, symptoms and potential complications that we must be aware of and monitor for. as nurses our primary function is to assist patients in accomplishing their adls (activities of daily living) as well as assisting the physician's in administering and carrying out their medical plan of care. how are you assisting this lady with her adls? with a fractured right humerus (the humerus is the bone of the upper arm) that pretty much leaves her with only one functional arm, how will she dress, eat, brush her teeth, use crutches or a walker? is she right handed or left handed and was the dominate arm the fractured one? how did she manage to fall in the first place? that is something that needs to be investigated because we don't want to send her back to the same situation to fall again. she will need major help with her adls. look at how low her hemoglobin and hematocrit are. what is going on there? what symptom will they produce that will affect her physical activity? you need a lab reference for some clues. what are you doing for her about her diabetes? her copd? her hypertension? with hypertension, copd and the immobility that will be imposed by this injury what complication(s) is(are) likely to occur and how can you care plan for them?

    before any diagnosing is done, an assessment of the patient is carried out first. assessment consists of:
    • a health history (review of systems) [font=arial unicode ms]
    • performing a physical exam
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
    you can see many examples of how i do this assessing on this thread before actually getting to the diagnosing: - help with care plans
  5. by   mfatony
    Thanks stearnsy!
  6. by   Stearnsy
    You are welcome. However, I have a couple of other bits of advice for you.

    1. it sounds like you need a care plan book. worth the $ x 1000
    2. read what the poster Daytonite wrote if you haven't already. it's worth the time, i promise.

    That's just my $.02
  7. by   mfatony
    Alright. I have a couple more question... if i was doing impaired walking as a diagnosis what are some interventions? and interventions for imbalanced fluid volume? and a goal for ineffective protection.

    O yea and i am looking into buying a care plan book..i figure it would help TREMENDOUSLY! haha
  8. by   Daytonite
    #1. . .there is no official NANDA diagnosis of Impaired Walking.

    #2. . .even if there were, your nursing interventions would be based on treating the symptoms and perhaps even address the cause that led you to name this problem as Impaired Walking. The same applies to the interventions for your fluid balance problem (Imbalanced Fluid Volume is not an official NANDA diagnosis). Treat the symptoms that are your evidence of this problem.

    #3. . .Goals are always what you predict are going to happen as a result of the performance of the nursing interventions you will order.
  9. by   mfatony
    On the new Nanda list for 2009-2011 the impaired walking and the imbalanced fluid volume are both on there. But anyways.. thanks for the help!
  10. by   Daytonite
    My fault, sorry. I still work from the 2007-2008 taxonomy. I see the Impaired Walking, but only Risk for Imbalanced Fluid Volume is in the new 2009-2011 taxonomy. I don't like using the new taxonomy because it is not alphabetized and its hard for me to find these newer diagnoses. Just make sure your nursing interventions treat the symptoms and you will be OK.
  11. by   belle87RN
    Quote from mfatony
    On the new Nanda list for 2009-2011 the impaired walking and the imbalanced fluid volume are both on there. But anyways.. thanks for the help!
    There's a new book! Goodness, maybe I should get that, although i only have till May, so I should be good.

    Here are a few i would do:

    Imbalance Fluid Volume or Risk for Imbalance Fluid volume r/t failure of regulatory mechanism. (I would imagine this is so, since her BUN is increased)
    Risk for Falls
    Risk for Infection
    Constipation or Risk for Constipation (r/t immobility)
    Activity Intolerance
    Readiness for Enhanced Knowledge (Always good if you need to do a teaching project, find something they may need to know about procedures or their condition and teach them about it)

    Hope these help!
  12. by   belle87RN
    I didn't read your entire post so I missed that you had all of the ones that I listed.

    - Does she have family taking care of her? You could use "Caregiver Role Strain" (Remember that your "client" isn't just the patient, it is the whole family)
    - What are her vitals? Remember that elderly people are more likely to have a low temperature over all and it goes even lower when they develop infection so you could use "Hypothermia" or "Ineffective Thermoregulation"
    - "Risk for unstable blood glucose"
    - Impaired Physical Mobility
    - Impaired Walking (Which is in my book, I saw there was a question to it by another poster. I use the Nursing Diagnosis Handbook by Ackley and Ladwig)
    - Any one of the "Self-Care" deficits could be appropriate.

    Anyway...thats a few that I can think of. You'll learn more as you get into it. This is my third semester for my RN degree and it's becoming more clear the more I do it. Don't give up hope!
    Last edit by belle87RN on Sep 19, '09
  13. by   mfatony
    Thanks everyone for the help! I really appreciate it!! O yea and i finally broke down and ordered a care plan book yesterday maybe it will help me out. My problem with this one was that having to plug all her meds in (which most were to do with her hear) but all that was really being focused on was the fx's.