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please help care plan questions

lopet19 lopet19 (New) New

ok well i have a 16 yo pt in a comatose state only responce to touch with moaning i need % good nandas i have infection rt opened area on frontal area of head aeb green discharge from area. her v/s are wnl she has she has necrosis on bil feet and , rhonchi in all lobes foot drop on r foot and she was in a swimming pool accident which caused a head injury a tonic clonic seizure and subdural hematoma also resolving pneumonia pls help need diagnosis maybe some interventions also thanx :eek:

Daytonite, BSN, RN

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

a nursing care plan is the determination of a patient's nursing problems (those are the nursing diagnoses) and the plan (strategies, nursing interventions) to do something for the problems. in the pursuit of a care plan the nursing process is the tool that is used to help us do the reasoning, or critical thinking, involved. it consists of several steps, but the first step, which is assessment is the most important because the entire care plan depends on what you discover during the assessment. assessment is a very broad activity and consists of information obtained from:

  • a health history (review of systems) - this is a 16 year old patient who is in a comatose state as a result of a swimming pool accident during which there was a head injury and subdural hematoma. the patient now has a tonic clonic seizures and a resolving pneumonia.
  • a physical exam - from what i could establish from your post you observed the following abnormal data: rhonchi in all lobes of the lung, foot drop of the right foot, green discharge from the open frontal area of the head, bilateral necrosis of the feet, and that the patient only responds to touch by moaning.
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - nothing about the patient's ability to perform adls is mentioned. lpns are primary assessors of patient adls and assisting patients in accomplishing their daily tasks. is suspect this patient has to have everything done for them, but you still need to state what it is that they cannot do.
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - a subdural hematoma and subsequent brain damage and resulting muscular dysfunction needs to be identified. did you review the physical therapy assessment on this patient? were they determined to have any paraplegia or quadriplegia? i am asking because of the foot drop that is present. what, if any movement of any extremities, is present? you must educate yourself about these conditions. see

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what drugs is the patient being given and why?

diagnosing is based upon the symptoms that the patient has. that is the same way the doctor diagnoses. our nursing diagnoses are based on symptoms that not only include physical abnormalities, but behavioral ones as well which is why we also assess how the patient behaves and reacts to their disease. since all you posted was:

  • rhonchi in all lobes of the lung
  • foot drop of the right foot
  • green discharge from the open frontal area of the head
  • bilateral necrosis of the feet
  • the patient only responds to touch by moaning

all i can diagnose is

  • ineffective airway clearance r/t retained secretions secondary to pneumonia aeb rhonchi in all lobes of the lung
  • impaired physical mobility r/t disuse and neuromuscular impairment secondary to head injury aeb foot drop of the right foot
  • impaired skin integrity r/t trauma, inflammatory response and physical immobilization aeb green discharge from the open frontal area of the head and bilateral necrosis of the feet
  • disturbed sensory perception, tactile r/t altered sensory reception aeb the patient only responds to touch by moaning, or this could be
    • impaired verbal communication r/t damaged central neurological system aeb the patient only responds to touch by moaning

nursing interventions are based upon the aeb items for each of the nursing diagnoses. fro example, for ineffective airway clearance r/t retained secretions secondary to pneumonia aeb rhonchi in all lobes of the lung some nursing interventions might be:

  • inspect the chest for abnormal movements with breathing
  • inspect the extremities for cyanosis, edema and clubbing of the digits
  • auscultate the lungs for diminished, absent and adventitious breath sounds q shift
  • monitor for increasing lethargy
  • have the patient sit upright to ease their breathing
  • encourage plenty of fluids to stay hydrated and use humidification
  • give oxygen, bronchodilators, mucolytics, expectorants and antibiotics as ordered and as needed

- - - - - - - - - - - - - - -

regarding the nursing diagnosis you had of infection rt opened area on frontal area of head aeb green discharge from area. . .there are a few problems with it.

  • infection is a medical diagnosis and you can't use it unless your instructors allow it.
  • the related factor must be the direct cause of the problem. an opened area on frontal area of head is not the underlying cause of the problem. the cause would be a traumatic injury that would lead to a bacterial invasion as the circumstances for an infection to occur.
  • it is enough to say green discharge. the aeb (as evidenced by) is a listing of your proof as the verification that you have of the problem. like detectives, we lay out the clues that led to our determination that this is the true diagnosis and why.

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

  • problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
  • etiology - also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
  • symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

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