Re: Help w/ care plan

care planning is about determining what the patient's nursing problems are and developing strategies to help them. it follows a very logical sequence. nursing problems involve the patient's response to their medical illness and how they are able to perform their adls (activities of daily living). in reading through the information you posted this sounds like a case study you were probably given. all the patient information is symptoms of cushing's syndrome. students usually ask what the nursing diagnoses are for a patient with some medical diagnosis and i tell them to break the medical diagnosis down into its signs and symptoms. that has already been done.

• cushing's syndrome
  • http://www.emedicine.com/med/topic485.htm
    
  • http://www.merck.com/mmpe/sec12/ch153/ch153e.html

it might be important to know what treatments the doctor is likely to order.

• http://www.fpnotebook.com/endo/adrenal/cshngsds.htm

the weblink to emedicine will give you the pathophysiology of this problem. the treatment is surgery to remove the tumor causing the problem or stop giving the steroids if that is what is being done to cause the cushing's. that is not a nursing decision. the nurses job is to help the patient cope with the symptoms.

• moon-shaped face
  
• truncal obesity with thin arm and legs
  
• dorsocervical fat pad (buffalo hump)
  
• muscle weakness
  
• noticed that her skin is fragile and bruises easily
  
• purple striae on abdomen
  
• b/p=152/96
  
• last menstrual period was 8 months ago
  
• coorifice, thin hair
  
• weight gain - 170 lbs
  
• fatigue
  
• has difficulty rising from low chairs
  
• 1+ non-pitting edema in her feet
  
• plasma cortisol level at midnight: 12.6ug/dl
  
• 24 hour urine sample for free cortisol: 375ug/24 hours
  
• dexamethasone suppression test: 12.2 ug/dl
  
• tsh: 2.2 mu/l (normal)
  
• fasting blood glucose: 122mg/dl

nursing diagnoses [determination of the patient's problem(s)] is based on the signs and symptoms that the patient has (the list above). every nursing diagnosis has a list of defining characteristics (signs and symptoms). what you have to do is use a nursing diagnosis reference to find nursing diagnoses that have some of these signs and symptoms and whose definitions sound like the problem the patient has. in the nursing diagnosis reference by nanda (north american nursing diagnosis association) called the taxonomy, signs and symptoms are referred to as defining characteristics. how can you get a copy of the taxonomy?

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

now, in looking at the list of signs and symptoms i can see problems of

• activity intolerance r/t generalized weakness aeb fatigue, muscle weakness and difficulty rising from low chairs
  
• excess fluid volume r/t excess production of cortisol aeb moon-shaped face, truncal obesity, dorsocervical fat pad, 1+ non-pitting edema in her feet and weight gain up to 170 lbs.
  
• disturbed body image r/t change in physical appearance aeb (patient verbalizes feelings or behaviors emphasizing the changes)
  
• risk for injury r/t altered clotting factors and weakness

perhaps you might see a few others. i did not even consider adls. the next step in developing a care plan is to take each nursing diagnosis and work on nursing interventions (i think that is what you are calling implementation). for each piece of evidence (symptom) that supports a problem (nursing diagnosis), you develop treatment for it.

for example, with activity intolerance r/t generalized weakness aeb fatigue, muscle weakness and difficulty rising from low chairs you address the fatigue, muscle weakness and her difficulty rising from low chairs.

• refer to physical therapy for evaluation
  
• assist the patient with standing [think about this: standing takes effort and since someone with cushing's is very fatigued and lacks energy, standing from a sitting position is a difficult thing for them to do]
  
• observe her breathing, heart rate and any changes in skin color before and after activity
  
• if patient becomes confused or lightheaded have her sit down immediately and rest
  
• note length of time and distance patient is able to tolerate walking each day

i leave the remainder of this care plan to you since it is your assignment and it would not be right for me to finish the entire project. you would never learn anything. i've given you a very good start already. good luck.