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Plan of care

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Can someone help me what to write on my plan of care. My patient whom I don't really know her diagnosis is in bed rests, she had a stroke and got paralyzed. I know that she has alzheimer's disease, but I don't know what exactly is her diagnosis. And in order for me to do my cARE plan, I need to put her diagnosis. Then, write down the nursing dianosis, the expected outcome and the nursing interventions. Please help!I need it asap. Thank you very much.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

i need to put her diagnosis.

they are stroke and alzheimer's disease. did you not recognize that these were medical diagnoses?

then, write down the nursing diagnosis, the expected outcome and the nursing interventions.

look up the pathophysiology and the signs and symptoms of the two medical diseases on these websites:

you were already told one of her major symptoms--paralysis. did they give any more specifics of this? left sided paralysis? right sided paralysis? upper body paralysis along with lower body paralysis? lower body paralysis? it makes a difference.

nursing diagnoses are based upon the signs and symptoms of the nursing diagnoses (nursing problems) that the patient has. bed rest is a medical order (treatment). but you must first establish what those signs and symptoms are by delving into the signs and symptoms of a stroke and alzheimer's disease. this is called applying information. to see more about how this is done in the care planning process see the posts on this thread:
https://allnurses.com/general-nursing-student/help-care-plans-286986.html
-
help with care plans.

after doing all of the above, if you are still having trouble determining the nursing diagnoses (the next step), post a list of the symptoms that you found and i will give you further help.

it says on the chart that her diagnosis is hyponic brain injury. Is this a right diagnosis?I only have to choose one on all of the diagnosis.

she also has DVT and this is what I want to do. Could you give me some ideas what would be my nursing diagnosis,expected outcome and nursing interventions plz? thank you.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

If that is what the face sheet on her chart says then that is what the doctor told the admitting office her diagnosis was. He would have also put her diagnosis on his history and physical exam.

Okay. So, could you please give me some ideas what would be my nursing diagnosis, expected outcome and nursing interventions? I'm struggling so much.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

i am trying to help you. i already told you that you need to look up the pathophysiology and the signs and symptoms of the patient's medical disease and that nursing diagnoses are based upon those signs and symptoms that the patient has. you must first establish what those signs and symptoms are by delving into the signs and symptoms of this patient's medical disease(s). if i give you the answers you will never learn anything about this patient's condition or how to find any of this information on your own. worse, you will never learn to think on your own. i am willing to help you, but not if you don't put any effort into this yourself. i already gave you websites on which to look up information. whether you want to look up stroke, alzheimer's disease or a dvt is up to you. i can't see the scenario information for this assignment, but you can. look back at what i first posted. i asked you to post a list of the symptoms that you found and i will give you further help if you cannot figure out how to come up with the nursing diagnoses. there are many examples of how i determine nursing diagnoses on the help with care plans thread. if you look at it you will see that a list of the patient's signs and symptoms which is derived from reading about their medical disease must be present. you cannot avoid doing this.

Thankz for the help.

I'm doing DVT and I'm almost done:)

My nursing diagnosis is pain related to inflammatory response in affected vein.

My expected outcome is tissue perfussion will be improved as evidenced by decreased edema and fewer feeling of discomfort.

My nursing intervensions are:

1.implement measures based on th client's individual risk factors to prevent hazards of immobility

2.managing venous stasis ulcers that involves healing the ulcer and to prevent recurrence

3.skin should be inspected daily and wash gently with warm water and soap

Please let me if its right!:)thankz

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

pain related to inflammatory response in affected vein aeb _________

the definition of pain (or
acute pain
, which is the nanda nursing diagnosis) is an
unpleasant sensory an emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months
(page 354,
nanda international nursing diagnoses: definitions and classifications 2009-2011
).
what are the patient's symptoms proving that she has pain?
i thought she was paralyzed. can she feel pain? how does she express that she has pain? assessment and description of pain includes the following:

  • where the pain is located

  • how long it lasts

  • how often it occurs

  • a description of it (sharp, dull, stabbing, aching, burning, throbbing)

    • have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain (is this patient able to speak?)

    [*]what triggers the pain

    [*]what relieves the pain

    [*]observe their physical responses

    • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility

    • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis

    • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness

this assessment data is necessary in order to develop outcome and nursing interventions.

my expected outcome is tissue perfussion will be improved as evidenced by decreased edema and fewer feeling of discomfort.

tissue perfusion has to do with oxygenation of the tissues--
not
pain. this is a wrong outcome that has nothing to do with pain. what are
feelings of discomfort
? how can anyone know what someone's feelings are? outcomes must predict the results of the nursing interventions. when i look at the nursing interventions for this problem of pain. . .none of the nursing interventions have anything to do with addressing the patient's pain (which i assume is in her leg because you say the cause of this pain is due to
inflammation in the affected vein
.

my nursing intervensions are:

1.implement measures based on th client's individual risk factors to prevent hazards of immobility

immobility has absolutely nothing to do with the patient's pain. immobility has to do with how the patient moves.

2.managing venous stasis ulcers that involves healing the ulcer and to prevent recurrence

a venous stasis ulcer is a break in the integument (skin) and this intervention does not address the problem of pain.

3.skin should be inspected daily and wash gently with warm water and soap

this, again, is doing absolutely nothing for the patient's pain.

interventions for pain are things such as:

  • assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
  • assess and document where the pain is located and what, if anything, makes it worse or better
  • observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
  • give pain medication as ordered
  • monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting

OKay. So, that means my work was wrong. I already handed in.:(But,thanks for the explanation. I'll go good next time.

I just checked her chart again today and she's not paralyzed.

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