So uncomfortable with my care plan

[Succubus]

Hi all,

I turned in a care plan today that I was SO COMPLETELY uncomfortable with. She was admitted for ORIF of right hip

PT DX:

PARADOXCYCAL AFIB

TIA

SEIZURES

HYPERLIPIDEMIA

DEMENTIA

V/S

BP 160/70

PULSE 108

RR 26

02 less than 90%

cap refill greater than 3

1+ edema in lower extremeties

elevated BUN, very low Hgb and RBC, doesn't use asscessory muscles, no JVD, irregular heart beat, lungs clear except lower lobes bilat, with fine crackles

MEDS:

Aspirin, keppra, 02 @ 2L continous NC, vicodin, lortab, calcium supplements, colace, ducolax, mom, she takes a couple of other meds, nothing major ((this is the stickler -- she is taking albuterol NEH for COPD)) but COPD was NOT EVEN LISTED IN CHART ANYWHERE nor prev medical hx. I don't see any "impending" CHF, although I know its probably later down the line. I have checked and double checked the chart and nothing!

On my night before clinicals primary dx was ORIF, I listed secondary seizures(get back to that)I know I only gave limited information, my nandas were, decreased cardiac output b/c of afib and tia, not able to adequately pump blood AEB some vs. My second was Ineffective tissue perfusion b/f edema and cap refill etc. I also chose acute pain. I let one instructor look over it and was told to remove cardiac output b/c I didn't have ekg's or ABG's to support finding, or inadequate s/s, told me to replace it with impaired skin integrity. I had to turn in today and another instructor told me to remove ineffective tissue perf and replace with impaired immobility b/c patient was admitted for orif and was told to remove secondary dx of seizures and replace with dementia. I thought that the TOP NANDAS are supposed to reflect WHAT WILL KILL THE PATIENT IMMEDIATELY. I am literally confused b/c I have gotten 3 different answers from 3 different instructors!!!!!!!!!!! so my top three were Impaired tissue integrity, Acute pain and impaired physical mobility. I don't understand where I went wrong with my NANDA's. PLEASE HELP!!!!!

[suzers26]

In my class we are instructed to do nsg dx based on primary dx, or the one which brought them to the hospital. Though this can change if another health issue arises or becomes primary, we would have to adjust it. So if she was admitted r/t ORIF the nsg dx should be based on that. Not saying the cardiac OP & tissue perfusion isn't important. Impaired tissue integrity & impaired mobility, as well as acute pain are priority for the reason she is there. They can also contribute to fluid build up in the lungs, impaired cardiac OP & tissue perfusion, etc...which in turn would effect her VS as well. If you can keep her pain under control, it will improve her mobility which will improve perfusion, cardiac OP, prevent further build up of fluid in the lungs, etc.

The albuterol is a basic bronchodialtor. I've found that sometimes there are Dx missing...no one's perfect. did you ask your patient if she had a history of resp. problems? You stated "lungs clear except lower lobes bilat, with fine crackles", in itself this can be a reason for a bronchodilator. It is used to control and prevent reversible airway obstruction as well as relief for acute/chronic bronchospasms. This can also all be related to immobility and pain, as if she is in pain she is not moving or doing coughing or deep breathing, allowing secretions to build up in lungs which can warrant the use of albuterol to prevent pneumonia, or other further complications.

I'm only halfway through my schooling, but that's how I understand it through my instructors. So if I'm wrong I hope someone corrects me :)

[Succubus]

Hmm thanks for that info, good insight. So my last instructor was right b/c thats exactly what she said. The other two only suggest that you write NANDA's for everthing thats wrong with patient. The top three NANDA's are what can KILL the patient today. Its prioritized by the ABC elimination, nutrition and maslow then risk dx's. Ok...thanks you have just summed up what the last person tried to explain to me. I understand her rationale now, didn't at first b/c I completed care plan based on the formula above AWESOME

[suzers26]

Glad that helped! Also, I wanted to mention the dementia as a secondary opposed to seizures is more than likely because the dementia there's really not much you can do about it. Many with dementia experience falls that often lead to fractures. And if they are confused it makes it harder to have them follow instructions to help the healing process. Chances are she's on phenobarbitol or something to control the seizures.

Sounds like your two instructors didn't clarify that very well. We can write a dx for the Afib, hyperlipidemia, etc. but chances are they are more under control with her meds than the admitting dx. If she develops an infection from impaired skin integrity or a blood clot/ resp. infection from immobility the other hx dx may move to a more priority spot. But that's why such a focus on the mobility & skin integrity, because if that's not taken care of at the present moment consequences/complications will be what kills her.

Just a suggestion, because instructors tend to expect different things, you may want to request a sit down with your instructors and explain your understanding to make sure it is correct with them. That will also help make sure they are on the same wave length also. And if they realize they confused one student, they might want to clarify to the rest of your class, because chances are others got confused also. Good Luck with your schooling!

[Succubus]

It was already on my mind, am going to do it on Monday. It has only taken you one reply to actually sum up the intricacies of a care plan. I will admit it...I absolutely ABHOR them and this is my third term and I ACTUALLY understand it after all this time. I know w/o a doubt that the last instructor used your method b/c she actually looked over my Twas the Night before Clinicals as well as my assessment before she gave me any information. The other two instructors never looked at either form, only asked her md dx and my NANDA's. Maybe, just maybe thats the primary reason why so many are still struggling to actually pull together a care plan. I am on it on Monday for sure, the one who made me modify it will be my clinical instructor for the duration of the year my last two terms, so I will follow her lead and speak to the other two to see if maybe there was a transmission error in our communication....THANKS again:yeah:

[RNTutor, BSN, RN]

Great discussion! I wanted to also add that in the post-school world of nursing...ALL of those NANDAs would be on your mind! But I definitely agree that for the purposes of writing a care plan for a class, you should focus on the admitting dx.

[Succubus]

Thanks...I subscribed to your blog. I see that you are a tutor!! Awesome, should be more like you? I have looked for tutors in my are forever but there are none available. Kudos to you for doing it

[RNTutor, BSN, RN]

Thanks...I subscribed to your blog. I see that you are a tutor!! Awesome, should be more like you? I have looked for tutors in my are forever but there are none available. Kudos to you for doing it

Thanks! Yep, I LOVE teaching, especially nursing students. Definitely my passion, and I can't get enough of it, so I decided to make it my job