Nursing Student!! Need some help please!

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Hi. I'm currently in my 3rd quarter of LPN school and was given an assignment to do a nursing care plan. I am sooo confused because we really havent gone over them and Im not sure where to start!

76 yr old male history of COPD Chief complaint pt fell out of bed while sitting up asleep and fractured left clavical also +3 edema bilaterally on arms with some seeping.

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

a nursing care plan is a determination of the patient's nursing problems (nursing diagnoses) and strategies on how to solve them (goals and nursing interventions). the nursing process is the tool we use to help us accomplish the plan of care. it has 5 steps, but the first 3 are probably the most important when it comes to developing a written care plan. this is how the steps of the nursing process are used to solve a common problem:

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).

as you can see, the nursing process keeps you thinking and performing in a rational manner. this is how the nursing process looks for care planning and what needs to be done in each of its 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)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected 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
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. (how to write a gaol statement: https://allnurses.com/forums/2509305-post158.html) they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]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 can start you off, but you really didn't provide much information.

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

  • 76 yr old
  • history of copd - what specific form of copd does he have (there are at least 3 different obstructive lung diseases)? does he have any symptoms of the copd? are they being treated (what medications or treatments is he getting)? did you assess his lungs, breathing and breathing during activity?
  • fell out of bed when asleep - is there a history of falling? why was he getting out of bed while sleeping? was he going to the bathroom? was he incontinent, or is he now incontinent, as a result of this?
  • fractured left clavicle - what medical treatment was done for this? surgery? splinting? how has this affected the patient's ability to move and perform his adls (activities of daily living)

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - if there is other abnormal data that you can now think of to add, now is the time to add it to the list below

  • +3 edema bilaterally on arms with some seeping - did you happen to assess the pulses, skin color and capillary refill in his arms?

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 - just as every medical diagnosis has a group of signs and symptoms, so does every nursing diagnosis. you need a nursing diagnosis reference to help you make these choices. the information given isn't much to make a diagnosis with but with a fractured clavicle and edema in the injured arm, the swelling is most likely because of traumatic injury. my father had a fractured clavicle in a car accident when he was in his 60's and because of that and his immobility (he had a previous stroke) the affected arm became edematous. i am puzzled as to why this patient's unaffected arm would also be weeping as well. is there an underlying heart condition like cor pulmonale along with the copd? was this the left or right arm?

  • ineffective tissue perfusion, peripheral r/t interrupted blood flow as a result of trauma aeb +3 edema in injured arm
  • impaired physical mobility r/t traumatically impaired clavicle aeb [specific evidence of what movements the patient is restricted in making]
  • any of the self-care deficits r/t traumatically impaired clavicle and pain aeb [specific evidence of what the patient cannot do for himself]
  • risk for infection r/t broken, weeping skin
  • risk for falls r/t age of 76 years and history of fall with injury

step #3 planning (write measurable goals/outcomes and nursing interventions) - at this point goals/outcomes are developed for each diagnosis. goals are the predicted results of the nursing interventions you will be ordering and performing. interventions specifically target the etiology of the problem or the abnormal data/signs and symptoms/evidence that support the existence of the problem. your overall goal is always aimed to alter or change something about the problem.

there is a sticky thread on care planning here:

hope this has given you some direction in how to start. please make this your work and not mine. if you need more help i will help.

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