Please help me in making my Nursing care Plan

Amy2005 · Sep 19, 2009

how about 'impaired physical mobility r/t painful joint" - does he have self-care deficit? Or chronic pain? Or risk for imbalanced nutritional status: less than body requirements?

Daytonite, BSN, RN · Sep 20, 2009

see the posts on https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

first, assemble your abnormal data (cues)

arthritis - look up the signs, symptoms and complications of this disease
swollen lower extremities - how is this affecting the patient?
cannot move lower extremities freely - need more specific information than "cannot move freely"
pain in lower extremities
he always feel hot and slightly febrile - what are the actual temperatures? is the wbc count elevated?
you need to assess the patient's ability to perform adls

the above are the patient's nursing problems. these can be turned into nursing diagnoses, but you need to supply more specific information about most of them before any more work can be done on diagnosis.

mkwatro · Sep 20, 2009

Thank you very much amy2005 and daytonite. :up: Your replies helped me alot.

mkwatro · Sep 20, 2009

He has a self-care deficit. He is always lying supine on bed and refuse to change position because of his aching lower extremities. He eats well with good appetite.

mkwatro · Sep 20, 2009

Could you also help me on what's gonna be my independent nursing intervention for my patient having this complaint? Please.

Daytonite, BSN, RN · Sep 20, 2009

Could you also help me on what's gonna be my independent nursing intervention for my patient having this complaint? Please.

What is your nursing diagnosis for "this complaint" (???) and what is the evidence that proves the problem exists? You need to be specific. I have no idea what you are talking about.

mkwatro · Sep 20, 2009

My nursing diagnosis is impaired physical mobility r/t painful joint. Maam/sir, my patient has osteoarthritis and I think his illness belongs to secondary osteoarth due to 1. injury ( his wife told me that he slide on the floor and his hip drops of the floor with great impact. 2. I think he has a metabolic condition specifically acromegaly due to the ff. sx: 1. Limited joint movement 2. Swelling of the bony areas around a joint 3. Thickening of the skin, skin tags 4. Widely spaced teeth.

He feels warm maam/sir his temp. increases like for 4 pm his temp. was 37.8 then after 4 hours it goes higher to 38.2. The air condition's thermostat was already in cooler but still he feels warm.

Daytonite, BSN, RN · Sep 20, 2009

The diagnosis would be Impaired Physical Mobility related to inflammation of the joints secondary to osteoarthritis AEB limited joint movement. The problem I have in helping you is "limited joint movement" is not specific enough information. What joint(s) are involved? Can he stand by himself or does he need someone to help him stand? Can he walk at all? Can he put any weight on his legs at all? Can he move his arms? Lift things? That information is necessary to know because it affects the interventions that will be ordered. Do you understand?

Thickening of the skin. . .how is this creating a problem? This is not Impaired Physical Mobility.

Widely spaced teeth. . .how is this creating a problem? This is not Impaired Physical Mobility.

mkwatro · Sep 21, 2009

Maam/sir thank you for the effort of explaining this to me clearly. Sorry maam/sir if my information is not specific because my instructor didn't explain to us clearly on what info we need to have a correct and effective nursing care plan. Hope you understand maam/sir. Now I know that I need to collect infos which are very specific, because I thought infos I collected are now sufficient for me to have a effective nursing care plan.

Maam/sir, the joints involve are the hinge joints because he couln't fold his lower extremities, he can't stand, he can't walk or even put weights on his leg at all. He is just lying supine in bed without moving his lower extremities because he doesn't want to feel the pain on it. He can move his arms but can't lift anything because everytime he lifted his arms it is shaking and sometimes he produce force on his arms. He didn't want to move his legs just like a paralyze one. And when his wife tried to lift his legs he told his wife to stop it because it is painful. He sometimes move his arms especially when he is being told to or lift it, but when it is on his own, he just put it on top of his stomach and that's it for one whole day. I think my patient has a trauma now on the pain he feels everytime he move his lower extremities and because of that now he feels weak. We tried to turn him to one side but he resist, too much supine position he developed bedsores on his butt.

Daytonite, BSN, RN · Sep 21, 2009

This is Impaired Physical Mobility related to inflammation of the joints secondary to osteoarthritis AEB unable to move arms or legs, bear weight on legs, stand or walk. Your nursing interventions are things you will do to compensate for his inability to move his arms and legs. What do your nursing textbooks tell you a nurse should do to keep patients doing some kind of movement when they are on total bedrest? Shouldn't he be turned and repositioned? Even though he resists turning you cannot stop turning and repositioning him or he will develop contractures. ROM also needs to be attempted.

Bedsores are a serious problem. You need to describe them. They are graded as Stage I-IV. The nursing diagnosis for this problem for this man is Impaired Skin Integrity R/T pressure and immobility AEB (description of the bedsores).

A big part of your problem is that you have to do better physical assessment of this patient in order to be able to diagnose his problems. This is making it almost impossible for me to help you.

mkwatro · Sep 21, 2009

Thank you very much maam. You really helped me alot. Hope that you could help me again next time. :)