Help With Nursing Care Plans

Daytonite, BSN, RN · Jan 27, 2008

First off, what are green dot precautions? I've never heard of that. This most likely is a specific facility thing and you need to clarify what that means for me because I'm sure it will have some significance to your care plan.

Now, to the care plan. Let me tell you what may not have been explained very well. A care plan is merely the written documentation of the nursing process. The nursing process is nothing more than a problem solving method. You and I have used this same problem solving method every day of our lives even before going to nursing school. The profession of nursing has just given it a name and some rules for us to follow in getting to the final solution(s). Let me give you an analogy that you can understand:

You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "what's wrong?" you're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it. A huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. What you have just done is step #1 of the nursing process--performed an assessment. You determine that you have a flat tire. You have just done step #2 of the nursing process--made a diagnosis. The little squirrel starts running like crazy in the wheel up in your brain. "what do I do?" you are thinking. You could call aaa. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. Good thing you took that class in how to do simple maintenance and repairs on a car! You have just done step #3 of the nursing process--planning (developed a goal and intervention). You get the jack and spare tire out of the trunk, roll up your sleeves and get to work. You have just done step #4 of the nursing process--implementation of the plan. After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive. Good. Everything seems fine. The spare tire seems to be ok and off you go and on your way. You have just done step #5 of the nursing process--evaluation (determined if your goal was met).

That little scenario above is the same process you go through in writing a nursing plan or solving any kind of problem for a patient in the clinical area. This is what we nurses do. I have jokingly referred to it for years as "stamping out fires". This, my darling, is what nursing school is all about--problem solving. The difference between taking care of a flat tire and what you are going to do a nurse is all the stuff you've been learning about anatomy and physiology, chemistry, pathophysiology, nursing interventions, yada, yada, yada. . .it all factors in because you gotta know a lot of stuff in order to assess and plan out the nursing care. But, it's still the same old problem solving method. These are the steps of the nursing process:

assessment (collect data from medical record and by doing a physical assessment of the patient)
nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

You want to follow the steps in that order, just like you do for a flat tire or when your electricity goes out or the school bus doesn't show up to pick the kids up to go to school. For a care plan you are merely memorializing your efforts on paper.

The first thing you need to do in writing a care plan is to look at the assessment data that you obtained. Since you are now home and the patient long gone, you only have what you were able to get from her medical record, what you observed and what you got from your physical assessment of her. This is what you listed in your post:

chest pain when I first came in" (subjective data)
shortness of breath
smoker
dizziness
noncompliance

Let me get noncompliance out of the way right off the bat. I'm assuming that this is something that you found in the chart that the doctor came up with. And, the reason I'm addressing this is because there actually is a nursing diagnosis of noncompliance. However, this is the definition of it and I want you to read it and see if this truly describes your patient's behavior: behavior of a person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan [doctor's orders] agreed on by the person (and/or family and/or community) and health care professional. In the presence of an agree-on, health-promoting or therapeutic plan, person's or caregiver's behavior is fully or partially nonadherent and may lead to clinically ineffective or partially ineffective outcomes. (page 146, Nanda-I Nursing Diagnoses: Definitions & Classification 2007-2008). In other words, it's like there had to have been a contract between the doctor and the patient and the patient broke it. If the patient from the get-go has said they weren't going to do what the doctor has been ordering, then it's not noncompliance by nanda's definition and you can't use that nursing diagnosis. So, what the doctor says is noncompliance and what nanda says is noncompliance are two different animals. Now, aren't you glad you took English and can understand these little nuances? Does that make sense to you? I'll address what you can do about this noncompliance at the end of this post.

Next, is the issue of this patient's medical diagnoses. She has one biggie: the copd. Copd comes in four varieties:

chronic obstructive asthma
chronic obstructive bronchitis
emphysema
chronic bronchitis with emphysema

Do you know which your patient had? If not, it may be possible to determine which she has by her symptoms. Copd'ers have all kinds of respiratory problems. Yet I don't see that you have listed many of the symptoms. Surely, you must have missed some of them. That's ok. Newbies aren't expected to be perfect at assessment, but I would hope that you would open a book and look up information on copd to see what you did miss noticing:

chronic obstructive asthma
- visible dyspnea
- ability to only speak a few words before pausing for breath
- use of accessory respiratory muscles to breathe
- diaphoresis
- hyperresonance (a loud booming sound to percussion over the lung)
- tachycardia
- tachypnea
- mild systolic hypertension
- inspiratory and expiratory wheezes
- prolonged expiratory phase of respiration
- diminished breath sounds
- an untreated asthma attack progresses to cyanosis, confusion, lethargy, status asthmaticus and respiratory failure
chronic obstructive bronchitis
- copious cough that produces gray, white or yellow sputum
- cyanosis
- use of accessory muscles to breathe
- tachypnea
- wheezing
- prolonged expiratory time
- rhonchi
- when there is development of cor pulmonale, pulmonary hypertension, or right ventricular hypertrophy
  - substantial weight gain
  - pedal edema
  - jugular vein distention
emphysema
- barrel chest
- pursed-lip breathing
- use of accessory muscles
- cyanosis
- clubbed fingers and toes
- tachypnea
- decreased tactile fremitus (the vibration felt when you hold your hand on the chest and the patient is speaking)
- decreased chest expansion
- hyperresonance
- decreased breath sounds
- crackles
- inspiratory wheeze
- prolonged expiratory phase with grunting respirations
- distant heart sounds
chronic bronchitis with emphysema
- the symptoms of chronic bronchitis and emphysema combined

If you see something above that you saw in your patient, copy it down now to add it to the list of assessment data which we are now going to start calling the patient's symptoms. The point of doing an assessment is to ferret out the patient's abnormal data, or symptoms. Symptoms are what you have to work with because symptoms are what cause the problems. Remember, we are involved in a problem solving activity.

I also don't want you to forget about this patient's cva. Did she have any residual effects from the cva? Any kind of sensory impairments of speech (communication), vision or mobility? What about any incontinence, hemiparesis or hemiplegia? Often people who have had strokes have to deal with adjustments to performing their adls (activities of daily living--bathing, dressing, transferring from bed or chair, walking, eating, toileting, and grooming). Did she have any of those?

Also, the fact that the patient has stents brings a couple of questions to mind. Did she have an angioplasty in the past? Does she have some kind of heart disease that is at the heart (no pun intended) of that chest pain she came in with? Oh, and the heart isn't the only place where stents are placed. I'm just assuming this stent is in one of her coronary arteries. Is she on blood thinners since she has this stent? By the way, think about the side effects of medications she is on because they can also be potential problems. Remember, the care plan is all about addressing problems or potential problems.

Ok, so all of the above covers everything you need to do to get through step #1 of the nursing process--assessment. From all that you will have developed a list of abnormal data, or symptoms that the patient has. This list is the most important information you need to make any care plan. It is the foundation of everything else you are going to do. Just like in the analogy of the flat tire I gave you. Everything was focused on that flat tire. Everything you do from here on is all about the symptoms on that list. It's just a bit more complicated than a simple flat tire.

Now, on to step #2, identifying the problems and giving them names. Nursing diagnoses are nothing more than names, labels, that you are going to attach to the problems. Don't make them more complicated than that or you'll get yourself confused and lost in the woods. I always suggest that students read the definition of each nursing diagnosis they use because that definition is the actual statement of the problem. The nursing diagnosis label is just the shortened version and it sometimes doesn't include important stuff of the entire problem, like with the diagnosis of noncompliance. If you have a current nursing care plan book, or even better, a nursing diagnosis book, the nanda (north american nursing diagnosis association) information will be listed there for each diagnosis. Over the years nanda has taken the pains to carefully describe and define these things to avoid confusion. Please take the time to read what they have to say so we are all on the same page. The only exception would be if your instructors have given you different information to go by.

Now, to actually picking nursing diagnoses. . .nursing diagnoses are always based upon the symptoms (abnormal data) your patient is having. Every single nanda nursing diagnosis has a listing of symptoms and related factors (underlying etiologies). Nanda calls the symptoms defining characteristics. Now, that you're in on that little secret there should be no stopping you. The related factors are the things that you will use as the "r/t" (related to) part of your nursing diagnostic statements if your instructors are requiring you to write 3-part nursing diagnostic statements [nursing diagnosis r/t xxx aeb xxx]. The beauty of nanda is that they have this stuff all listed out for you and many of the nursing care plan books and nursing diagnosis books have re-printed it! Some of it can be seen online for free for certain commonly used nursing diagnoses.

The most obvious diagnosis you should be using, and I'm basing this on what I know about copd and the one symptom you've listed: shortness of breath, is impaired gas exchange. Its definition (in other words, the patient's problem) is excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. (page 94, Nanda-I Nursing Diagnoses: Definitions & Classification 2007-2008). Does that sound about right? Shortness of breath (dyspnea) is one of the defining characteristics (symptoms) of this nursing diagnosis. Why is this happening (the related factor)? Well, in this case, it would be nice to know the pathophysiology of the copd. This is why I brought up the issue of the four varieties of copd and why we need to have some knowledge of the patient's medical disease process. This is where, dare I say it, critical thinking rears it's ugly head. With most copd, changes are occurring at the alveolar level and this is the reason the gas exchange is screwed up. If you look at the related causes for impaired gas exchange that nanda lists, there are only two:

alveolar-capillary membrane changes
ventilation perfusion imbalance

Ventilation perfusion imbalances are due to debris and exudate that clog up the bronchioles and alveoli as in pneumonia, but also when there is a lot of mucus or pus, as in the case of pneumonia. However, in the case of alveolar-capillary membrane changes, they are referring to permanent damage to the structural membranes as occurs with diseases like copd. So, bingo! Alveolar-capillary membrane changes are your related factor for your diagnostic statement. (see how critical thinking can get you places?) so, your first nursing diagnostic statement will be: impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath. Ta-da! (I forgot to mention that everything that follows "aeb" in your diagnostic statements is always the patient's symptoms from your symptom list.) Does the rational of how I got to this make sense to you? I've just completed step #2--determined that patient's problem and come up with the nursing diagnosis.

Step #3 is to plan the goals and nursing interventions. Again, these are all based on the patient's symptoms on the symptom list. For impaired gas exchange they will be based on the symptom of "shortness of breath". I'm not going to list any for you. I'm leaving that for you to do. This is the part of the care plan where you also need to do some customizing of the interventions to the patient. But I am going to give you two websites that have nursing interventions and I am also going to assign you to check the index of your textbooks for "dyspnea" and "shortness of breath" as well as "copd" and "emphysema" and read to see what is listed there. You need those resources for your rationales on your nursing interventions anyways. When you get to these websites I want you to notice the nanda information that is printed at the very beginning of each of them.

Nursing interventions come in four types:

assess/monitor/evaluate/observe (to evaluate the patient's condition)
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)

For each symptom you should be able to squeeze out one of each type depending on how good you are at bs'ing, I suppose. Ha! Ha! I should be more serious about this. I've done too many care plans, I guess.

For her chest pain you can diagnose her with acute pain. For her dizziness you can diagnose her with either impaired physical mobility if it's related to her cva and it's giving her problems with her walking and moving around, or risk for injury if she's in danger of falling and splitting her head or some other body part open (is that the green dot precautions?). As for her smoking, which she really needs to quit for a number of good reasons (I'll let you find out what those are as part of your education!) you can tack on ineffective health maintenance (rather than using noncompliance). The diagnostic statement would look something like this: ineffective health maintenance r/t denial of the effects of smoking aeb continual lack to stop smoking

And those, dear heart, are your three/four nursing diagnoses, goals and interventions. You got a lot of work to do on this to complete the care plan. If you are in need of more help with this, don't hesitate to ask.

nightmare, RN · Jan 27, 2008

Wow, Daytonite, you are one excellent teacher!

blessy2 · Mar 2, 2008

Want to get some ncp on dyspnea. Thanks a lot!

Daytonite, BSN, RN · Mar 2, 2008

blessy2 said:
Want to get some ncp on dyspnea. Thanks a lot!

You are not going to find any on the Internet. You have to make your own based on the symptoms that patient has.

gaajr1, RN · Mar 2, 2008

Daytonite,

Hats off to you! You are so good in explaining things. I for one read almost all your explanations, though I still have time before I start my clinicals. Thank you very much for the time and effort you put in to answer our questions.

It would be my dream to have a mentor like you.

UM Review RN, ASN, RN · Mar 2, 2008

scrubaway010 said:
Daytonite,
Hats off to you! You are so good in explaining things. I for one read almost all your explanations, though I still have time before I start my clinicals. Thank you very much for the time and effort you put in to answer our questions.
It would be my dream to have a mentor like you.

I'm learning so much more here than I ever did in my Nursing classes. (Then again, I'm not a nervous wreck about my GPA, either.)

Thanks, Daytonite!

kmora · Sep 2, 2008

Daytonite you are a great help and a great mentor. No one had been so clear with the explanation! Thank you so much you're awesome!

Nursemrb07, LPN · Nov 8, 2008

I have been an LPN for 2 years and have got the hang of doing a care plan for a patient. My problem is doing a care plan for OOPS! A Health Promotion Plan for a Community. I did a Clinical at a homeless shelter for men. I was doing BP and education on getting the flu vaccine. The Majority of my BP's taken were normal. The Big problem I noticed for several of the men was poor dental hygiene. Some had rotten teeth still in their mouths, some had no teeth at all, almost all had teeth that were rotten or decayed, along with bad breath. I just am not sure what diagnosis is right to use, how to consider all 3 domains of learning into my outcome, and how to get a primary, secondary and tertiary prevention for my Interventions. Any suggestions or advise would be appreciated.

Daytonite, BSN, RN · Nov 8, 2008

nursemrb07 said:
I have been an LPN for 2 years and have got the hang of doing a care plan for a patient. My problem is doing a care plan for OOPS! A Health Promotion Plan for a Community. I did a Clinical at a homeless shelter for men. I was doing BP and education on getting the flu vaccine. The Majority of my BP's taken were normal. The Big problem I noticed for several of the men was poor dental hygiene. Some had rotten teeth still in their mouths, some had no teeth at all, almost all had teeth that were rotten or decayed, along with bad breath. I just am not sure what diagnosis is right to use, how to consider all 3 domains of learning into my outcome, and how to get a primary, secondary and tertiary prevention for my Interventions. Any suggestions or advise would be appreciated.

Your post took me back to the days when I worked for a large city hospital. Bad dental care was very common among the indigent we saw. Many of our indigent patients got one final trip before discharge to the dental clinic for full mouth extractions. We jokingly called it the "discharge special".

I'm not being mean here, but doing care plans involves the use of the nursing process. I hope you weren't referring to opening up a care plan book as the way to "doing a care plan" because you won't find "poor dental hygiene" in a care plan book, but you can care plan this using the nursing process. The nursing process, however, requires that you perform its steps in sequence with assessment being very crucial. You've obviously identified the problem and evidence of it (rotten teeth in their mouth, no teeth at all, bad breath) but you don't have the cause/pathophysiology. At a dental exam they would be asked if they brush their teeth and how often they brush. And, why they don't brush like recommended? Use what is asked of you at your own dental exams as a guide. If these people are homeless, maybe they don't have toothbrushes, toothpaste, god forbid, floss or even access to running water. Does a shelter even provide those things? Dental care isn't even something that is provided as part of medical insurance plans, so payment for dental care is often a problem, let alone getting a toothbrush and toothpaste!

For this crowd of folks I would use ineffective health maintenance r/t lack of money/equipment/supplies/provisions/service [pick one or more based on your assessment of the situation] aeb rotten teeth in their mouth, no teeth at all and bad breath (or wording to that effect). Interventions are aimed at altering the related factors or the doing something about the evidence. This is usually a good diagnosis for using teaching interventions. Access also needs to be facilitated for getting supplies (toothbrushes, toothpaste, floss) and dental care by dentists to those patients who have the motivation and will use them. That is what you are tasked to do with a community based care plan like this.

The nursing process:

assessment
nursing diagnosis
planning
implementation
evaluation

Nursemrb07, LPN · Nov 8, 2008

Thank you for your reply. I did my care plan on Impaired dentition r/t ineffective oral hygiene AMB Halitosis, excessive plaque, enamel discoloration, tooth fractures, premature tooth loss of primary teeth, client stated he had not brushed teeth in 2 days.

Daytonite, BSN, RN · Nov 9, 2008

Nursemrb07 said:
Thank you for you'r reply. I did my care plan on Impaired dentition r/t ineffective oral hygiene AMB Halitosis, excessive plaque, enamel discoloration, tooth fractures, premature tooth loss of primary teeth, client stated he had not brushed teeth in 2 days.

That works, but it sounds like it is for one individual patient. You gave the impression that this was a care plan for a community which to me means a group of clients and not just one. I also thought you were going more for a teaching strategy to work into the plan.

Help With Nursing Care Plans

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