PLEASE HELP!! Careplan hel

Daytonite, BSN, RN · Feb 7, 2009

a care plan is nothing more than your strategies for doing something about the nursing problems that a patient is having. to help in doing that you use the nursing process to help you organize your thinking and plan.

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. you should also consider all the medical treatments that the doctor has ordered (medications) and their side effects and complications.

bronchiolitis
- see http://www.merck.com/mmpe/sec19/ch277/ch277k.html
[*]hx of gerd

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - if this patient's bronchiolitis is due to asthma then the low wbc is not surprising since the body may have been depleting wbcs trying to fight off this inflammation for some time. the abnormal blood profile and platelets are probably an iron deficiency anemia and could be reflective of what is turning into a chronic inflammatory process going on in the lungs. if that is the case, this child is also at risk for developmental delays.

diarrhea (see: http://www.merck.com/mmpe/sec19/ch266/ch266h.html)
coughing
wheezing
diaper rash
wbcs 4.1
hct 30.6
mcv 72.1
mch 24.8
rdw 16.4
plt 576

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 - every nursing diagnosis has a definition, related factors and defining characteristics. you can find this information in the nanda taxonomy. this taxonomy is reprinted in many nursing care plan books that have nursing diagnosis information, nursing diagnosis books, the appendix of taber's cyclopedic medical dictionary, and is included for about 75 of the most commonly used diagnoses that are included on these two websites:

before you start choosing nursing diagnoses for a patient you need to have evidence, or proof (signs and symptoms), that there is a problem. in essence, you have data and are looking for a name for it. a nursing diagnosis is a label--a name--for a nursing problem. its true description is in it's definition which you will find in the nanda taxonomy. you have some very good data to work with but without knowledge of the pathophysiology of the diseases that are going on you will lack insufficient knowledge to complete the related factors for your diagnostic statements. these are the problems i would diagnose in priority order based on the information you posted:

ineffective airway clearance r/t reflux of gastric contents into the respiratory track and bronchi aeb coughing and wheezing
imbalanced nutrition: less than body requirements r/t poor feeding, decreased appetite, and increased metabolic need aeb iron depletion and diarrhea
impaired skin integrity r/t fecal soiling, mechanical friction and moisture aeb diaper rash [see: http://kidshealth.org/parent/newborn/basics/diaper_rash.html]

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem - now you begin working on goals and nursing interventions. goals are what you predict will happen as a result of the interventions you will order. think of your nursing interventions as what you will order to be done for those symptoms you found way back in step #1 that support your nursing diagnoses. so, for example, for ineffective airway clearance r/t reflux of gastric contents into the respiratory track and bronchi aeb coughing and wheezing i will write interventions targeting the coughing and wheezing--things that i, as a nurse, can do for them.

now, after reading this you may remember some things about the patient that you will want to add to the writing of this care plan which will change some things. make sure you read about this patient's medical diseases so you have an understanding of what they are experiencing and why the symptoms are occurring.

good luck.

Deannalynn · Feb 7, 2009

THANK YOU SOOO MUCH! I have been reading through many of your posts and really hoped that you would reply to me. I really appreciate your help!