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quick care plan questions


Hello. I'm writing a care plan for a 67 year old male who's medical dx is rhabdomyolysis. He weights 156 kg. My teacher suggested impaired gas exchange because he was on 2L nasal cannula. I'm not sure how come up with 3 goals and 9 nursing actions because i really think the only reason he was on the NC was because he is over weight and couldn't breath properly with all the weight pushing on his chest. He was on an inhaler, but no chest pain and normal respirations....I didn't know if i'm better off doing something with is obesity???

Daytonite, BSN, RN

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

a nursing diagnosis has to based on abnormal symptoms that the patient has. was he breathing properly or not? there is a nursing diagnosis called ineffective breathing pattern that accounts for all the different ways patients do not breathe properly, but you need to describe them. see the defining characteristics (signs and symptoms of this diagnosis on this webpage: ineffective breathing pattern.

you should also look up rhabdomyolysis. did he have any bruises or skin damage as a result of this? there is a nursing diagnosis for skin damage.

your goals and nursing interventions are always based upon the abnormal symptoms that the patient has. these determine your nursing diagnoses. they are the foundation of the entire care plan. goals will be what you predict will happen if your nursing interventions for the abnormal symptoms are carried out as you ordered.

My care plan is done. so there is no turning back now. Thanks for the help though. and yes i did research on rhabdo before i even cared for him. he did have weakness in his rt arm and one of my dx was imparied skin integrity because he had some other places on him too

Was he on oxygen before his admission?

If not, the O2 is likely not solely d/t his weight (since I'm thinking he didn't suddenly gain weight before admission ).