Ok so here is the deal...I am having trouble with these lovely things called nursing care plans. My teacher wants a nursing diagnosis, a long term goal, a short term goal, 3 interventions and 3 rationales. I am having difficulty coming up with a second short term goal with different interventions than the first short term goal...can anyone help me?
My first diagnosis is: Impaired Skin Integrity r/t scratches AMB itching and disruption of skin surface (epidermis).
My short term goal is: Client's skin integrity will not diminish within next 6 months.
My interventions are: Assess skin on chest and upper extremities every morning.
Apply lotion to itchy area 3 times a day.
Apply clean, dry clothing over affected area daily.
My second diagnosis is: Impaired Physical Mobility r/t decreased muscle strength AMB limited ROM and unsteady gait.
My short term goal is: CLient will increase muscle strength from a level 3 to a level 4 on the muscle strength scale by 12/18/08.
My interventions are: Assess for pain before, during and after activities.
Assist with active ROM in mornings on Monday, Wednesday and Friday.
Participate in PT/OT 5x week.
I am stumped because I feel like I covered everything in my first short term goal.
Any advice would be appreciated! Thanks so much! :nuke:
The only book they suggested we have is the NANDA diagnosis book. The small one that has all the diagnoses in it. They never told us about a book that would help us complete the care plans! For awhile I was doing everything from my head....it sucked!
Specializes in med/surg, telemetry, IV therapy, mgmt.
the only book they suggested we have is the nanda diagnosis book. the small one that has all the diagnoses in it. they never told us about a book that would help us complete the care plans! for awhile i was doing everything from my head....it sucked!
as new learners no one should be doing any diagnosing or care planning from their head. that is how mistakes get made. medical students don't diagnose or prescribe care without consulting reference materials. pulling information out of your head on the spot comes later after working with many, many patients who have had the same or similar conditions. that takes time and experience. if your instructors are giving you the impression that this information should just pop out of your head boom-boom-boom on the spot in clinical, i think they are terribly wrong.
the "nanda diagnosis book" you are referring to is published by nanda and is actually the official taxonomy. it is included in all those care plan and commercial diagnosis books that are sold. those authors must pay a royalty to nanda to include it in their books. it is what i call the bare bones of the nursing diagnoses. if you understand how the nursing diagnoses are constructed that $25 book is worth it's price. a new edition is coming out this month.
what you are getting in those other books is extra stuff like suggested outcomes, interventions and rationales. the problem is they cannot cover every possibility for every patient situation. if you follow the posts on these forums like i do you will also find that these commercial books do not include the newest nursing diagnoses depending on their date of publication. risk for unstable blood glucose is an example of a diagnosis that was added by nanda in 2006 but has not made it to all of the newer care plan and nursing diagnosis references yet, but has created some arguments about its authenticity between students and instructors in classrooms.
I'm also struggling with developing a care plan and with Subjective/objective data. I've read posts on Subj/obj data, but am not sure if a mother's report of her child is subjective?
The assignment:
given 4 year-old child's file with past health history, exams, etc (w/o meeting child)
Supposed to categorize the information we gathered from the documents in a nursing process form with the headings:
Assessment, Norms/guidelines/ EBP for Assessment (also needed for planned action), Nurs.Diag., Client outcomes, Plan/Interventions, Evaluation.
In his health history form "frequent otitis media with febrile seizures" was documented. Tx: "diazepam rectal gel", no mention of antibiotics or how many ear infections he has had. He has tubes in both ears and was "unable to screen" 9/07 & 10/07, but passed 4/08. Speech was documented as "understood by mother, difficult to understand by unfamiliar listener.
"yes" to engages in daily play, no reponse listed for frequency of colds
not anemic, food group servings all exceed rda's, fast food & soda rare
Last physical 11/07: height 38.75 in, 38.1 lbs BP= 80/150
lives with his mother & little bro., living below the federal poverty level.
My diagnosis (doesn't have to be highest priority): Risk for delayed speech and language development r/t otitis media.
Questions:
Subjective/objective data: is diet subjective? b/c mother reported and we can't measure?
Speech info- Is medical record info like this Subjective or objective?
Client Outcomes-
Plan Implementation- Would referral to an ENT be appropriate yet or to taking the DDST?
Evaluations/Continuing Outcomes
I know this is super long, and I probably should have chosen an easier diagnosis b/c I don't relly know what I am doing yet. Could anyone shed some light on this for me? I would REALLY Appreciate any insight offered!
My instructor never told me about care plan books either! I couldn't understand why it took me so long to do them, and kept getting points taken off. grrr...
Specializes in med/surg, telemetry, IV therapy, mgmt.
hello all,
i'm also struggling with developing a care plan and with subjective/objective data. i've read posts on subj/obj data, but am not sure if a mother's report of her child is subjective?
the assignment:
given 4 year-old child's file with past health history, exams, etc (w/o meeting child)
supposed to categorize the information we gathered from the documents in a nursing process form with the headings:
assessment, norms/guidelines/ ebp for assessment (also needed for planned action), nurs.diag., client outcomes, plan/interventions, evaluation.
in his health history form "frequent otitis media with febrile seizures" was documented. tx: "diazepam rectal gel", no mention of antibiotics or how many ear infections he has had. he has tubes in both ears and was "unable to screen" 9/07 & 10/07, but passed 4/08. speech was documented as "understood by mother, difficult to understand by unfamiliar listener.
"yes" to engages in daily play, no reponse listed for frequency of colds
not anemic, food group servings all exceed rda's, fast food & soda rare
last physical 11/07: height 38.75 in, 38.1 lbs bp= 80/150
lives with his mother & little bro., living below the federal poverty level.
my diagnosis (doesn't have to be highest priority): risk for delayed speech and language development r/t otitis media.
questions:
subjective/objective data: is diet subjective? b/c mother reported and we can't measure?
speech info- is medical record info like this subjective or objective?
client outcomes-
plan implementation- would referral to an ent be appropriate yet or to taking the ddst?
evaluations/continuing outcomes
i know this is super long, and i probably should have chosen an easier diagnosis b/c i don't relly know what i am doing yet. could anyone shed some light on this for me? i would really appreciate any insight offered!
can someone help me??? i turned this in to my instructor and she gave me back some feedback... but at this point i feel completely brain dead.
part 1
patient introduction:
88 yo caucasion widow, protestant admitted on 4/15/07 with complaints of pain in lower back, left lower extremities, abdomen and unsteady gait. reason for visit: deep vein thrombosis of superficial femoral. history of falls. previously admitted to st. agnes hospital and then transferred to dorsey for falls. past medical history: chronic arthritis, htn, gastroeosphageal reflux, chronic ischemic heart disease, peripheral vascular disease, deep vein thrombosis, muscle atrophy, acute pancreatitis, and osteoarthrosis, osteoporosis, gerd, chronic atoxia, sip, incontinence, rbbb, hyperthyroidism, onychomycosis, pathological fracture of tibia, and malaise fatigue, left medial tibial plateau fracture. past surgical history: bladder suspension 3 times, total abdominal hysterectomy and bilateral salpingo-oophorectomy. code status b[color=#3366ff] (what does this mean): support live care prior to cardiac/respiratory arrest. dnr. no cpr. allergies: asprin & ultram. patient is also allergic to certain types of metals, rashes occur, types are unknown. patient requested long term residence at dorsey. capable of adl’s. ambulates with assistance of 2 and uses wheelchair. loc: awake, alert, and oriented to person, place, time, and situation.
abnormal diagnostic data: laboratory, radiology, ultrasound, ekg, mri… (include the date, actual finding, and why the result might be abnormal for this patient).
rbc: 3.7 x 106/ul
normal: 3.8-5.6 x 106/ul . low value may be a result of chronic illness, acute anemia, or dietary deficiency.
hemoglobin: 10.9 g/dl
normal: 11.5-17 g/dl. low value may be a result of anemia from lack of physical activity or nutritional deficiency.
hematocrit: 32.4%
normal: 34.0-44%. low value may be a result of anemia
[color=#3366ff]for full points- need to relate low rbc, hgb, and hct specifically to this patient… meaning what disease process lead or would contribute to low levels and why.
albumin: 3.0 g/dl
normal: 3.5- 5.5 g/dl. low values may be due to malnutrition of protein or increased capillary permeability from dvt dz.[color=#3366ff] (more detail as to how deep vein thrombosis would lead to low albumin level
globulin: 2.7 g/dl
a/g ratio: 1.1
co2 total: 28 mmol/l
creatine 0.61
bun: 34 mg/dl [color=#3366ff] (how is this patient’s kidney function?)
normal: 5-26 mg/dl. high value may be a result of dehydration from furosemide medication. many people with severe heart conditions are kept slightly dehydrated by the diuretics they take to prevent fluid buildup in their lungs, and they often have reduced blood flow (underperfusion) to the kidneys.[color=#3366ff]yes- how does “underperfusion” to the kidneys affect bun?
bun creatine ratio: 56[color=#3366ff] (what was the creatine ration? 56:__
normal: 8-27. high value because of bun’s value.
glucose: 78 mg/dl
chloride: 109 mmol/l
normal: 97- 108 mmol/l. high value may be a result of dehydration or anemia. it may also be from hyperventilating (increased c02 levels) [color=#3366ff] (was your patient “hyperventilating:? with a result of respiratory alkalosis.
sodium: 141 mmol/l
potassium: 4.7 mmol/l
calcium: 8.4 mg/dl
normal: 8.5- 10.6 mg/dl. low value may be a result of vitamin d deficiency [color=#3366ff]yes… what else specific to this patient would affect vit d? from osteoarthrosis dz.[color=#3366ff]-how would this disease process affect ca
date??????amylase[color=#3366ff] do you know the level?: elevated lipase/amylase. indicative of a pancreatitis dz.
ct and x-rays:
pancreas: no gb stones
test was implemented because it’s a painful symptom of pancreatitis.
l. knee: vascular calcifications noted.
perhaps related to complaints of leg pain[color=#3366ff] yes- how does this affect perfusion and relate specifically to this patient.
r. ribs: mild degenerative changes are present at r. acromioclaviclar joint.
indicative of osteoarthrosis.
l. ankle: osseous structures are diffusely osteopenic.
indicative of osteoporosis dz.
lle venous doppler evaluation:
there was partial compressibility of l. femoral vein with normal spontaneous and phasic flow in the l. superficial femoral, popliteal and tibial system. normal response to compression with augmented flow at all levels tested with the exception of l. common femoral vein which was not compressible.
indicative of lle pain and edema with result of dvt diagnosis.
pathophysiology flowchart:
gggggf
gerd
acid induced vasoconstriction and compromised coronary perfusion[color=#3366ff] ??
pancreatitis
chronic ischemic heart disease [color=#3366ff]
claudication in legs
angina
dvt[color=#3366ff] discuss complications of this
- albumin: 3.0 g/dl
due to increased capillary permeability
htn pvd
[color=#3366ff]angina does not lead to htn
[color=#3366ff]pancreatitis to chronic ischemic heart ds is a
[color=#3366ff]big leap- relate how this disease process affect body system
rbbb
[color=#3366ff]this flow chart addresses “several” of the
[color=#3366ff]processes
[color=#3366ff]this patient has a significant past history of (_falls?___) what? how does it relate?
-edema (nonpitting)[color=#3366ff] why and where does this fit in?
morbidity/mortality statistics:
gerd:
piero fisichella, md, (2008) states the following mortality and morbidity:
in addition to the typical symptoms (eg, heartburn, regurgitation, dysphagia), abnormal reflux can cause atypical symptoms, such as coughing, chest pain, and wheezing. additional atypical symptoms from abnormal reflux include damage to the lungs (eg, pneumonia, asthma, idiopathic pulmonary fibrosis), vocal cords (eg, laryngitis, cancer), ear (eg, otitis media), and teeth (eg, enamel decay).
approximately 50% of patients with gastric reflux develop esophagitis. esophagitis is classified into the following 4 grades based on its severity
grade i - erythema
grade ii - linear nonconfluent erosions
grade iii - circular confluent erosions
o grade iv - stricture or barrett esophagus (barrett esophagus is thought to be caused by the chronic reflux of gastric juice into the esophagus. barrett esophagus occurs when the squamous epithelium of the esophagus is replaced by the intestinal columnar epithelium. barrett esophagus is present in 8-15% of patients with gerd and may progress to adenocarcinoma.
pancreatitis:
ghattas khoury, md, (2008) states the following mortality and morbidity:
although acute pancreatitis should be noted, chronic pancreatitis has a more severe presentation as episodes recur.
acute respiratory distress syndrome (ards), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock all may be systemic manifestations of acute pancreatitis in its most severe form
mild edematous pancreatitis occurs in about 80% of presentations, and the mortality rate is below 1%.
severe acute pancreatitis occurs in about 20% of presentations, with a mortality rate reaching 24%.
chronic ischemic heart disease:
michael e. zevitz, md, states that, “in the united states, approximately 14 million persons have ischemic heart disease and its various complications. chf, as a result of ischemic cardiomyopathy, has become the most common discharge diagnosis in us hospitals” (zevitz, 2006).
hypertension:
sat sharma, md, (2008) states the following mortality and morbidity:
in the framingham heart study, the age-adjusted risk of congestive heart failure was 2.3 times higher in men and 3 times higher in women when highest blood pressure was compared to the lowest. multiple risk factor intervention trial (mrfit) data showed that the relative risk for coronary heart disease mortality varied from 2.3-6.9 times higher for persons with mild-to-severe hypertension compared to persons with normal blood pressure.
the relative risk for stroke ranged from 3.6-19.2. the population-attributable risk percentage for coronary artery disease varied from 2.3-25.6%, whereas the population-attributable risk for stroke ranged from 6.8-40%.
pvd:emedicinehealth states the following mortality and morbidity:
it occurs mostly in people older than 50 years. peripheral vascular disease is a leading cause of disability among people older than 50 years and in those with diabetes.
about 10 million people in the united states have peripheral vascular disease, which translates to about 5% of people older than 50 years.
the number of people with the condition is expected to grow as the population ages.
men are slightly more likely than women to have peripheral vascular disease.
peripheral vascular disease is more common in smokers, and the combination of diabetes and smoking almost always results in more severe disease.
rbbb:
glenn t. wetzel, md, phd. (2008) states the following mortality and morbidity:
surgically induced right bundle branch block generally results in no clinically significant acute hemodynamic consequences, and it has a benign course over the long term. in rare cases, if right bundle branch block is associated with injury to the his-purkinje system (eg, left anterior hemiblock, first-degree av block), it can progress to complete heart block and sudden death.
patients who have undergone tetralogy of fallot repair and have a qrs duration more than 180 milliseconds may be at risk for ventricular arrhythmias and sudden death.
patients with familial right bundle branch block may have a benign course, whereas those with right bundle branch block and brugada syndrome or kearns-sayre syndrome are at risk for sudden death.
dvt:
donald, schreiber, md, cm (2008) states the following mortality and morbidity:
approximately 1 person in 20 will develop a dvt in the course of his or her lifetime. about 600,000 hospitalizations per year occur for dvt in the united states.
death from dvt is attributed to massive pe, which causes 200,000 deaths annually in the united states. pe is the leading cause of preventable in-hospital mortality.
[color=#3366ff]m&ms very good
medications
drug name
generic and trade
dose/freq/route
drug class
for this patient/in this situation. be specific
reason this patient is receiving
lisinopril
prinivil
meloxicam
omeprazole
oyst shell calcium with vit.d
oysco 500+d
paroxetine
paxil
polyethylene glycol 100% powder
miralax
acetaminophen
tylenol ex. strength
acetaminophen
tylenol
atenolol
tenormin
calcitonin (rdna)
fortical
furosemide
lasix u-d
gabapentin
neurontin
senna with docasate
senokot s u-d
vitamin d softgel
drisdol
antacid with simethicone liquid
mylanta
milk of magnesia
12.5 mg/ 12 hrs/po
10 mg tab with 2.5 mg to equal 12.5 mg
15 mg daily/po
20 mg daily at 600 hr/ po
1 tablet/t.i.d/po
10 mg daily/po
1 scoop in 8 ounce water or juice at 2200 hr/ po
500 mg at bedtime/ po
650 mg/t.i.d/po
2 tabs of 325 mg to equal 650 mg
25 mg/ everyday/po
200 units (1 spray)/ everyday/ alternating nostrils
suppresses gastric secretion by inhibiting hydrogen/ potassium atpase enzyme system in gastric parietal cell; blocks final step of acid production
calcium carbonate, antacid, calcium supplement
selective serotonin reuptake inhibitors (ssri)
laxative
nonopiod analgesic
nonopiod analgesic
antihypertensive
parathyroid agents (calcium regulator)
loop diuretic
anticonvulsant
laxative-stimulant
calcium supplement
antacid
saline laxative, antacid
antihypertensive for htn
osteoarthrosis
gastroesophageal reflux disease (gerd)
osteoporosis, gerd
depression
constipation
pain
pain
htn
osteoporosis [color=#3366ff](relate labs)
edema, htn
prevent nerve pain in lower extremities.
constipation
osteoporosis[color=#3366ff] (relate labs)
[color=#3366ff]why so important in this patient?
dyspepsia (indigestion) from gerd
gerd and constipation
assessment: date/time of assessment:_12/4/08 @ 1100
problems
psychosocial assessment (general description of emotional/psychosocial status):
awake and responsive, makes eye contact. shows no acute distress. awake and responsive, makes eye contact. reports no current pain. “my leg only hurts at night. i don’t like to move around in the daytime” no complaints of any other discomfort.
mother, mid 50s, died postoperative from dvt surgery. father, 86 yo, died of pneumonia in nursing home[color=#3366ff].
risk for depression and hopelessness r/t limited communication[color=#3366ff] (provide a bit more assessment data that leads to this problem)
impaired physical mobility aeb poor gait and wheelchair use[color=#3366ff] (this probably belongs in different section- nothing in this psycho/social assessment section addresses this)
alteration in comfort : pain aeb patient
reports of pain
anticipatory grieving[color=#3366ff] (why) [color=#ffc000]r/t night time leg pain.
t: 97.3 f p: 56 beats/min r:18 breaths/min
bp: 159/77 saturation: 88%
[color=#3366ff]are there any problems?
[color=#ffc000]high bp, indicative of hypertension[color=#3366ff]
neurological:
reports no loss in smell. able to smile, frown, puff cheeks and clench jaws equally, tongue midline without tremor, pink buccal mucosa; dry, no tonsils, facial sensation intact to soft touch, eoms intact, voice clear, shrugs shoulders against resistance, confrontation tests shows decreased peripheral vision. rosenbaum test: 14/14, no hesitancy with corrective lens. heard 1 word out of 5 with whisper test. able to identify written number on palm: peripheral sensation intact, touches thumb to fingers: coordination intact, identifies accurate position touched: proprioception intact.
potential for alteration in cognition r/t age
impaired hearing loss r/t whisper test results
risk for impaired memory r/t age
musculoskeletal:
shoulders and body are symmetric. biceps, triceps and hand grasp strength 5/5 bilat., dorsi and plantar ankles and quad str 3/5 on r, 2/5 on l. able to ambulate with assistance of 2 bed to chair. strong ue rom. rle & lle quad weaknesses. gait: ataxic
bilat. nonpitting edema in lower extremities. brachioradialis dtr responsive. unable to assess for le rom due to [color=#3366ff]non?incompliance [color=#3366ff]of with patient.
risk for fall aeb impaired mobility[color=#3366ff] and what else?
decreased muscle strength r/t limited rom[color=#3366ff] more specific- stated strong rom upper extremities.
risk for impaired skin integrity r/t immobility
activity intolerance r/t quad weakness
cardiovascular:
no visible chest pulsation or heaves, pmi at 5th ics l mcl. no tenderness. apicial 76/min. s1 loudest at apex, s2 loudest at base. no murmurs, rub or gallop. no thrills upon palpation. bilat. radial pulse +3/4. no carotid bruits heard. no clubbing of nails, no cyanosis.
[color=#3366ff]missing important assessment info specific to this patient- think vasculature and perfusion[color=#3366ff]
altered tissue perfusion r/t limited mobility[color=#3366ff] what else?
sedentary lifestyle
assessment:
problem
respiratory/thorax:
symmetric expansion of lungs. bilateral tactile fremitus with no soreness of posterior chest wall. percussion of resonance over lung fields. no chest wall tenderness or pain with palpation, no visible deformities or lesions. no rales, rhonchi or wheezes. good breath sounds ant and post.
risk for impaired oxygenation r/t sedentary lifestyle
risk for aspiration[color=#3366ff] why?
g-i/abdominal:
symmetrical and flat contour. notable striae, no lesions. even pale skin color throughout. no pain or tenderness with light palpation. no visible pulsations, no vascular sounds. bowel sounds active in all 4 quads. bm once a day, last bm was last night. reports good appetite. “i’ve been gaining 2 pounds for the past 3 months.” currently 158 pounds.
patient reports that after taking asprin, “it hurts my stomach.” reaction to ultram is not noted
risk for constipation r/t limited mobility
risk for diarrhea [color=#3366ff]?why [color=#ffc000]aeb laxative use.
g-u:
incontinence. wears absorbent pads day and night. pads are changed x2 night. “i go all the time, i can’t possibly tell you how often. once i stand up, i have no control.” patient cannot recall color and other characteristics of urine.
potential for alteration in urinary elimination patterns
incontinence aeb patient’s report
risk for impaired skin integrity aeb use of absorbent pads
integument:
skin
dry and thin skin. warm temp. throughout, very pale in appearance. cap refill 3 seconds over fingers, no clubbing. decreased skin turgor. edema le. no lesions.
[color=#3366ff]
risk for infection[color=#3366ff] why? [color=#ffc000]r/t thinned skin
risk for impaired coagulation[color=#3366ff]?? why [color=#ffc000]aeb pale skin color r/t poor perfusion
risk for impaired skin integrity
dehydration aeb poor turgor
knowledge base:
balance and transfer training
energy management
rom exercises
bladder exercises [color=#3366ff]good
identify two priority pathophysiologic problems amenable to nursing interventions:
1. risk for falls [color=#3366ff]yes r/t pvd [color=#3366ff]not on the mark… somewhat close. aeb dvt, edema, patient complaint of pain, immobility and history of falls. [color=#3366ff](better wording needed for nanda dx)
2. hypertension r/t chronic ischemic heart disease aeb blood pressure 159/77.[color=#3366ff] (good problem statement but not a nanda nursing dx)
identify two priority psychosocial problems amenable to nursing interventions:
1. ineffective-coping aeb by ssri medication, decreased social interaction r/t incontinence, immobility, feelings of hopelessness[color=#3366ff] good but need to support “hopelessness” in the assessment data section.
2. risk for compromised human dignity aeb feelings of powerlessness[color=#3366ff] again.. i did not see this supported in assessment data.
patient problem: risk for falls r/t pvd aeb metastatic dvt, edema, patient complaint of pain, immobility and history of falls. (how many problems do we have to write short term goals for? just 1 or all the ones we stated above?)[color=#3366ff] see rubric… “one realistic outcome for each problem stated = average score.
in 2 weeks is to perform bed mobility/ transfers with guarding of one and assistance of 1 to wheelchair when needed.
the nurse will:
[color=#3366ff]good interventions
1. determine risk of falling by using an evaluation tool such as the fall risk assessment, the conley scale, or the fraint tool for fall risk assessment.
2. thoroughly orient the client to environment. clear any clutter. place the call light within reach and show how to call for assistance; answer call promptly.
3. ensure that the chair or wheelchair fits the build, abilities, and needs of the client to ensure propulsion with legs or arms and ability to reach the floor, eliminating footrests and minimizing problems with shearing.
4. refer to physical therapy for strengthening exercises, gait training, and help with balance to increase mobility. [color=#3366ff]repeated below
5. if the client is feels weak, use a walking belt or two nursing staff members when ambulating the client.
6. encourage the client to wear glasses and use walking aids when ambulating.
7. if the client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as rising slowly, remaining seated several minutes before standing, flexing feet upward several times while sitting, gsitting down immediately if feeling dizzy, and trying to have someone present when standing.
[color=#3366ff]how will you evaluate this and when would you know you need to make a “change in plan”?
short term goal in 2 weeks, patient will be able to perform daily exercises to improve overall le strength and rom
1. consult with physician for a safety evaluation before beginning an exercise program; if program is approved, begin preparing for exercises.
2. schedule physical therapy sessions to have specialist teach exercises that are relevant to the patient.
3. help patient practice rom everyday at a set schedule.
4. provide emotional support to encourage patient to keep trying.
5. before activity, observe for and, if possible, treat pain. ensure that the client is not oversedated.
6. obtain any assistive devices needed for activity, such as gait belt, walker, cane, crutches, or wheelchair, before the activity begins.
psychosocial nursing care plan
patient problem: ineffective coping aeb by ssri medication, decreased social interaction r/t incontinence, immobility, feelings of hopelessness.
expected outcome
nursing interventions
evaluation/
change in plan
short term goal in 2 weeks, patient will express realistic self-evaluation and increased sense of self-esteem.[color=#3366ff] did she have “low self esteem”?
1. assess the client's level of depression and physical reactions to hopelessness.
2. treat the patient with courtesy and respect. converse at client’s level, providing meaningful conversation while performing care.
3. if irrational thoughts or fears are present, offer the client accurate information and encourage him or her to talk about the meaning of the events contributing to the feelings of distress.
4. encourage the client to use positive self-talk such as, "i can do this one step at a time,” "right now i need to breathe and relax,” "i don't have to be perfect.”
5. provide clients with a means to listen to music of their choice or audiotapes. provide a quiet place and encourage clients to listen for 20 minutes.
6. encourage client to participate in activities scheduled for the day by the facility.
short term goal in 2 weeks, patient will communicate their needs and negotiate with others to meet needs
1. observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation.
2. help the client set realistic goals and identify personal skills and knowledge.
3. encourage the client to make choices and participate in the planning of care and scheduled activities
4. be supportive of coping behaviors; allow the client time to relax. actively listen to complaints and concerns.
5. teach the client to problem solve. have the client define the problem and cause, and list the advantages and disadvantages of the options.
Specializes in med/surg, telemetry, IV therapy, mgmt.
my comments are in purple. there are some things that i may have missed. there was a lot to look over.
88 yo caucasion widow
pain in lower back, left lower extremities, abdomen
unsteady gait
deep vein thrombosis of superficial femoral
history of falls
chronic arthritis
htn
gastroeosphageal reflux
chronic ischemic heart disease
peripheral vascular disease
deep vein thrombosis
muscle atrophy
acute pancreatitis
osteoarthrosis
osteoporosis
gerd
chronic atoxia
sip
incontinence
rbbb
hyperthyroidism
onychomycosis
pathological fracture of tibia
malaise fatigue
left medial tibial plateau fracture
past surgical history: bladder suspension 3 times
total abdominal hysterectomy and bilateral salpingo-oophorectomy
code status b[color=#3366ff] (what does this mean): support live care prior to cardiac/respiratory arrest. dnr. no cpr
allergies: asprin & ultram. patient is also allergic to certain types of metals, rashes occur, types are unknown.
ambulates with assistance of 2 and uses wheelchair
rbc: 3.7 x 106/ul
normal: 3.8-5.6 x 106/ul . low value may be a result of chronic illness, acute anemia, or dietary deficiency.
hemoglobin: 10.9 g/dl
normal: 11.5-17 g/dl. low value may be a result of anemia from lack of physical activity or nutritional deficiency.
hematocrit: 32.4%
normal: 34.0-44%. low value may be a result of anemia
[color=#3366ff]for full points- need to relate low rbc, hgb, and hct specifically to this patient... meaning what disease process lead or would contribute to low levels and why.
albumin: 3.0 g/dl
normal: 3.5- 5.5 g/dl. low values may be due to malnutrition of protein or increased capillary permeability from dvt dz.[color=#3366ff] (more detail as to how deep vein thrombosis would lead to low albumin level) dvt is a disease of clotting and clotting factors which are synthesized in the liver. 60% of albumin is protein that is formed in the liver and, therefore, a measure of hepatic function. if the liver is faulty in its job of one thing, it is likely to be faulty in another. if the liver is not producing enough platelets and fibrin so that a dvt formed, then, it would not be surprising to find that albumin levels were low because it was also failing to produce enough of that as well.
globulin: 2.7 g/dl
a/g ratio: 1.1
co2 total: 28 mmol/l
creatine 0.61
bun: 34 mg/dl [color=#3366ff](how is this patient's kidney function?)
normal: 5-26 mg/dl. high value may be a result of dehydration from furosemide medication. many people with severe heart conditions are kept slightly dehydrated by the diuretics they take to prevent fluid buildup in their lungs, and they often have reduced blood flow (underperfusion) to the kidneys.[color=#3366ff]yes- how does "underperfusion" to the kidneys affect bun?
bun creatine ratio: 56[color=#3366ff] (what was the creatine ration? 56:__) bun/creatinine ratio ideally should be between 10:1 and 20:1. it determines normal renal clearance. when creatinine levels rise, it indicates chronic disease is present. the bun rising by itself indicates an acute disease process in the kidney
normal: 8-27. high value because of bun's value.
glucose: 78 mg/dl
chloride: 109 mmol/l
normal: 97- 108 mmol/l. high value may be a result of dehydration or anemia. it may also be from hyperventilating (increased c02 levels) [color=#3366ff](was your patient "hyperventilating:? with a result of respiratory alkalosis.
sodium: 141 mmol/l
potassium: 4.7 mmol/l
calcium: 8.4 mg/dl
normal: 8.5- 10.6 mg/dl. low value may be a result of vitamin d deficiency [color=#3366ff]yes... what else specific to this patient would affect vit d? vitamin d is necessary to absorption of calcium from foods that are ingested so it can be utilized by the body. from osteoarthrosis dz.[color=#3366ff]-how would this disease process affect ca
date??????amylase[color=#3366ff] do you know the level?: elevated lipase/amylase. indicative of a pancreatitis dz.
ct and x-rays:
l. knee: vascular calcifications noted.
perhaps related to complaints of leg pain[color=#3366ff] yes- how does this affect perfusion and relate specifically to this patient. these calcifications could be within the layers of the vasculature (the patient does have chronic ischemic heart disease and peripheral vascular disease) so that the lumens of her arteries and veins are narrowed
r. ribs: mild degenerative changes are present at r. acromioclaviclar joint.
indicative of osteoarthrosis.
l. ankle: osseous structures are diffusely osteopenic.
indicative of osteoporosis dz.
lle venous doppler evaluation:
there was partial compressibility of l. femoral vein with normal spontaneous and phasic flow in the l. superficial femoral, popliteal and tibial system. normal response to compression with augmented flow at all levels tested with the exception of l. common femoral vein which was not compressible.
indicative of lle pain and edema with result of dvt diagnosis.
pathophysiology flowchart:
chronic ischemic heart disease
dvt[color=#3366ff] discuss complications of this complications include pulmonary embolism. i have also seen patients who went on to develop gangrene and loss of the limb because they refused to have any treatment for the clot.
- albumin: 3.0 g/dl
due to increased capillary permeability the increased capillary permeability is due to the inflammatory response and release of histamine by local mast cells. here is the pathophysiology of inflammation: https://allnurses.com/forums/f50/histamine-effect-244836.html
[color=#3366ff]pancreatitis to chronic ischemic heart ds is a
[color=#3366ff]big leap- relate how this disease process affect body systempancreatitis does not relate to chronic ischemic heart disease at all. it stands alone.
rbbb i do think the rbbb slowed her heart rate down enough to contribute to the formation of the clot along with some liver disease (not enough platelets and fibrin as well as albumin being manufactured together along with her sedentary lifestyle) made it a matter of time before it happened.
[color=#3366ff]this flow chart addresses "several" of the
[color=#3366ff]processes
[color=#3366ff]this patient has a significant past history of (_falls?___) what? how does it relate? low calcium and protein contribute to bone loss.
-edema (nonpitting)[color=#3366ff] why and where does this fit in?
medications
drug name
generic and trade
dose/freq/route
drug class
for this patient/in this situation. be specific
reason this patient is receiving
lisinopril
prinivil
meloxicam
omeprazole
oyst shell calcium with vit.d
oysco 500+d
paroxetine
paxil
polyethylene glycol 100% powder
miralax
acetaminophen
tylenol ex. strength
acetaminophen
tylenol
atenolol
tenormin
calcitonin (rdna)
fortical
furosemide
lasix u-d
gabapentin
neurontin
senna with docasate
senokot s u-d
vitamin d softgel
drisdol
antacid with simethicone liquid
mylanta
milk of magnesia
12.5 mg/ 12 hrs/po
10 mg tab with 2.5 mg to equal 12.5 mg
15 mg daily/po
20 mg daily at 600 hr/ po
1 tablet/t.i.d/po
10 mg daily/po
1 scoop in 8 ounce water or juice at 2200 hr/ po
500 mg at bedtime/ po
650 mg/t.i.d/po
2 tabs of 325 mg to equal 650 mg
25 mg/ everyday/po
200 units (1 spray)/ everyday/ alternating nostrils
suppresses gastric secretion by inhibiting hydrogen/ potassium atpase enzyme system in gastric parietal cell; blocks final step of acid production
calcium carbonate, antacid, calcium supplement
selective serotonin reuptake inhibitors (ssri)
laxative
nonopiod analgesic
nonopiod analgesic
antihypertensive
parathyroid agents (calcium regulator)
loop diuretic
anticonvulsant
laxative-stimulant
calcium supplement
antacid
saline laxative, antacid
antihypertensive for htn
osteoarthrosis
gastroesophageal reflux disease (gerd)
osteoporosis, gerd
depression
constipation
pain
pain
htn
osteoporosis [color=#3366ff](relate labs) see below
edema, htn
prevent nerve pain in lower extremities.
constipation
osteoporosis[color=#3366ff] (relate labs)calcium: 8.4 mg/dl is low along with a low albumin level. half of the protein bound form of calcium exists in albumin, so when albumin levels are low, as this patient's are (albumin of 3.0 g/dl), then the calcium will also reflect a low level as well. this low albumin is generally associated with states of malnutrition and malnutrition is the most common reason for hypocalcemia. the ionized form of calcium, the other half of calcium in the body, is not affected by changes in serum albumin. [color=#3366ff][color=#3366ff]why so important in this patient? calcium is an electrolyte that must be constantly be replaced through dietary intake or by pharmacological means. it can indicate that the patient isn't eating enough foods high in calcium or getting adequate calcium supplementation (oyst shell calcium with vit.d). in addition, because of this patient's history of falling she is at risk for pathologic fractures because of the weakening of her bone structure.
dyspepsia (indigestion) from gerd
gerd and constipation
assessment: date/time of assessment:_12/4/08 @ 1100
problems
psychosocial assessment (general description of emotional/psychosocial status):
awake and responsive, makes eye contact. shows no acute distress. awake and responsive, makes eye contact. reports no current pain. "my leg only hurts at night. i don't like to move around in the daytime" no complaints of any other discomfort.
mother, mid 50s, died postoperative from dvt surgery. father, 86 yo, died of pneumonia in nursing home[color=#3366ff].
impaired physical mobility aeb poor gait and wheelchair use[color=#3366ff] (this probably belongs in different section- nothing in this psycho/social assessment section addresses this)
impaired physical mobility is a problem of movement and not one of psychosocial need. also, you have no related factor for it.
alteration in comfort : pain aeb patient
reports of pain
again, no related factor. what is causing the pain? and, you need to state that the pain is in her leg:
alteration in comfort r/t inflammatory process aeb patient statement that "my leg only hurts at night."
anticipatory grieving[color=#3366ff] (why) [color=#ffc000]r/t night time leg pain.
i don't see it.
risk for depression and hopelessness r/t limited communication[color=#3366ff] (provide a bit more assessment data that leads to this problem)
this is pretty much the same as anticipatory grieving, isn't it? and i don't see it.
t: 97.3 f p: 56 beats/min r:18 breaths/min
bp: 159/77 saturation: 88%
[color=#3366ff]are there any problems? bp of 159/77 is slightly high ando2 sat of 88% is not normal.
[color=#ffc000]high bp, indicative of hypertension
neurological:
reports no loss in smell. able to smile, frown, puff cheeks and clench jaws equally, tongue midline without tremor, pink buccal mucosa; dry, no tonsils, facial sensation intact to soft touch, eoms intact, voice clear, shrugs shoulders against resistance, confrontation tests shows decreased peripheral vision. rosenbaum test: 14/14, no hesitancy with corrective lens. heard 1 word out of 5 with whisper test. able to identify written number on palm: peripheral sensation intact, touches thumb to fingers: coordination intact, identifies accurate position touched: proprioception intact.
potential for alteration in cognition r/t age
impaired hearing loss r/t whisper test results
whisper test results are evidence of the problem not the cause of the problem.
risk for impaired memory r/t age
musculoskeletal:
shoulders and body are symmetric. biceps, triceps and hand grasp strength 5/5 bilat., dorsi and plantar ankles and quad str 3/5 on r, 2/5 on l. able to ambulate with assistance of 2 bed to chair. strong ue rom. rle & lle quad weaknesses. gait: ataxic
bilat. nonpitting edema in lower extremities. brachioradialis dtr responsive. unable to assess for le rom due to [color=#3366ff]non?incompliance [color=#3366ff]of with patient.
decreased muscle strength r/t limited rom[color=#3366ff] more specific- stated strong rom upper extremities.
limited rom would not cause decreased muscle strength. that doesn't make any sense to me. beside the fact that this is not an official nanda diagnosis, it seems that the kind of thing that would cause a person to have decreased muscle strength might be poor nutrition, neural impairment or an injury to the body part. aeb would be specific statements about the rom such as "can only move the left arm as high as the level of the shoulder".
activity intolerance r/t quad weakness
quad weakness is not a cause of this problem. this diagnosis is about the patient getting insufficient oxygen during activity. vital signs that show how the heart, respiratory or blood pressure changes with activity are among the defining characteristics of this diagnosis. people who are activity intolerant can't take more than a few steps or walk a few feet before they start having heaving respirations (sometimes wheezing) heart rates and blood pressures that elevate if the nurses bother to take them before and after, becoming diaphoretic and they tell you they have to sit down because they are not going to be able to make it any further (fatigue). if they are on telemetry they can have ekg changes. you really don't have the evidence to prove that this problem exists. when you see someone like this you won't forget it.
your impaired physical mobility diagnosis belongs here.
risk for impaired skin integrity r/t immobility
risk for falls aeb impaired mobility[color=#3366ff] and what else? a whole slew of stuff for this lady: her age, a prior history of falling, prior history of fracture of the tibial plateau fracture as well as a pathologic fracture of the tibia, use of a wheelchair, history of arthritis, osteoporosis, incontinence, current pvd with dvt and on diuretic and laxative.
cardiovascular:
no visible chest pulsation or heaves, pmi at 5th ics l mcl. no tenderness. apicial 76/min. s1 loudest at apex, s2 loudest at base. no murmurs, rub or gallop. no thrills upon palpation. bilat. radial pulse +3/4. no carotid bruits heard. no clubbing of nails, no cyanosis.
[color=#3366ff]missing important assessment info specific to this patient- think vasculature and perfusion where's you assessment of the legs, especially the leg with the dvt? the pulses? leg circumference? homan's sign? redness, swelling, warmth?
altered tissue perfusion, peripheral r/t limited mobility[color=#3366ff] what else?
sedentary lifestyle
perfusion to the peripheral (leg) is altered because that is where the dvt is. limited mobility did not cause this. what is this dvt doing to the patient? nanda tells you it is an interruption of the blood flow. does that sound right? now, what are the aebs? pulses? sensation? homan's positive or negative? skin color change? skin temperature? edema?
assessment:
problem
respiratory/thorax:
symmetric expansion of lungs. bilateral tactile fremitus with no soreness of posterior chest wall. percussion of resonance over lung fields. no chest wall tenderness or pain with palpation, no visible deformities or lesions. no rales, rhonchi or wheezes. good breath sounds ant and post.
risk for impaired oxygenation r/t sedentary lifestyle
no. the lungs will get filled with secretions first, then infection will occur before an oxygenation problem.
risk for aspiration[color=#3366ff] why? i don't know either, unless she chokes on her sputum.
g-i/abdominal:
symmetrical and flat contour. notable striae, no lesions. even pale skin color throughout. no pain or tenderness with light palpation. no visible pulsations, no vascular sounds. bowel sounds active in all 4 quads. bm once a day, last bm was last night. reports good appetite. "i've been gaining 2 pounds for the past 3 months." currently 158 pounds.
patient reports that after taking asprin, "it hurts my stomach." reaction to ultram is not noted this patient has gerd, a history of pancreatitis and takes omeprazole. she had testing done to rule out gallstones while she was hospitalized because of some abdominal pain that she must have complained about.
risk for constipation r/t limited mobility
possible, except she eats well and reports a daily bm. you didn't get information about the consistency of her stools.
risk for diarrhea [color=#3366ff]?why [color=#ffc000]aeb laxative use. there are no aeb with "risk for" diagnoses because they are non existent problems, therefore, there can be no evidence to support them. i've got a better diagnosis for you to use.
risk for acute pain r/t irritation of stomach
g-u:
incontinence. wears absorbent pads day and night. pads are changed x2 night. "i go all the time, i can't possibly tell you how often. once i stand up, i have no control." patient cannot recall color and other characteristics of urine.
potential for alteration in urinary elimination patterns
incontinence aeb patient's report
this is no longer a "potential for". it is an actual problem, so call it a
total urinary incontinence r/t bladder dysfunction secondary to bladder collapse aeb patient's report that
"i go all the time, i can't possibly tell you how often. once i stand up, i have no control."
the woman has had 3 bladder suspensions and a tah/bso. how many kids did she have lady partslly? i'd be incontinent too!
risk for impaired skin integrity aeb use of absorbent pads
you can't use aebs which are the proof (clues) of the existence of a nursing problem (nursing diagnosis) with a "risk for" diagnosis. a "risk for" diagnosis is an anticipated problem that doesn't exist yet. your r/t (risk factor) for skin breakdown with someone who is incontinent is that their skin might be resting in the pee long enough to break down. you just have to put that in professional language.
risk for impaired skin integrity r/t the presence of urine and diapering.
and, by the way, the "use of absorbent pads" is a nursing intervention and not a legitimate aeb (defining characteristic) for this diagnosis.
integument:
skin
dry and thin skin. warm temp. throughout, very pale in appearance. cap refill 3 seconds over fingers, no clubbing. decreased skin turgor. edema le. no lesions. with a dvt i would have done circumferential measurements of both lower legs at their widest points for comparison.
risk for infection[color=#3366ff] why? [color=#ffc000]r/t thinned skin your assessment doesn't say she has thin skin, so it doesn't sound rational. the reason a person might be at a risk for an infection if they don't already have one is because their immune system is whacked (low). i didn't see anything about her wbcs being low. is she on antibiotics that could suppress the work of the immune system? didn't see any ordered. an existing infection can turn into sepsis, but that doesn't seem to be the case here. i don't think you can use this.
risk for impaired coagulation[color=#3366ff]?? why [color=#ffc000]aeb pale skin color r/t poor perfusion
coagulation is already impaired so it is no longer a risk. that's how she got the clot in the first place. where are her pt and ptt labs? pale skin is a result of poor circulation in the leg not a problem of screwed up coagulation (low or high platelets and fibrin).
risk for impaired skin integrity
r/t impaired circulation and fluid retention
dehydration aeb poor turgor
knowledge base:
balance and transfer training
energy management
rom exercises
bladder exercises [color=#3366ff]good bladder training program--the bladder exercises can be worked in. with her history, she's beyond the bladder exercises.
identify two priority pathophysiologic problems amenable to nursing interventions:
1. risk for falls [color=#3366ff]yes r/t pvd [color=#3366ff]not on the mark... somewhat close. aeb dvt, edema, patient complaint of pain, immobility and history of falls. [color=#3366ff](better wording needed for nanda dx)
this is not an actual problem.
2. hypertension r/t chronic ischemic heart disease aeb blood pressure 159/77.[color=#3366ff] (good problem statement but not a nanda nursing dx)
hypertension is a medical diagnosis and not a nanda diagnosis. chronic ischemic heart disease is also a medical diagnosis and cannot be used unless restaed in different wording.
do these have to be diagnoses you already came up with? this is what i would use. . .
total urinary incontinence r/t bladder dysfunction secondary to bladder collapse aeb patient's report that "i go all the time, i can't possibly tell you how often. once i stand up, i have no control.".
identify two priority psychosocial problems amenable to nursing interventions:
i have the same problem as your instructor. . .there is no data to support using either of these. i looked at your sychosocial assessment and there isa nothing there to work with. does she socialize with others? go to activities? she is on paxil. why? what were her symptoms that she nneded to go on this drug? at this point, if it were my grade i's be making stuff up.
??? risk for social isolation r/t incontinence and impaired mobility
1. ineffective-coping aeb by ssri medication, decreased social interaction r/t incontinence, immobility, feelings of hopelessness[color=#3366ff] good but need to support "hopelessness" in the assessment data section.
2. risk for compromised human dignity aeb feelings of powerlessness[color=#3366ff] again.. i did not see this supported in assessment data.
patient problem: risk for falls r/t pvd aeb metastatic dvt, edema, patient complaint of pain, immobility and history of falls. (how many problems do we have to write short term goals for? just 1 or all the ones we stated above?)[color=#3366ff] see rubric... "one realistic outcome for each problem stated = average score.
i'm not even addressing this because i don't think they are priority needs.
expected outcome
nursing interventions
evaluation/
change in plan
short term goal
in 2 weeks is to perform bed mobility/ transfers with guarding of one and assistance of 1 to wheelchair when needed.
the nurse will:
[color=#3366ff]good interventions
1. determine risk of falling by using an evaluation tool such as the fall risk assessment, the conley scale, or the fraint tool for fall risk assessment.
2. thoroughly orient the client to environment. clear any clutter. place the call light within reach and show how to call for assistance; answer call promptly.
3. ensure that the chair or wheelchair fits the build, abilities, and needs of the client to ensure propulsion with legs or arms and ability to reach the floor, eliminating footrests and minimizing problems with shearing.
4. refer to physical therapy for strengthening exercises, gait training, and help with balance to increase mobility. [color=#3366ff]repeated below
5. if the client is feels weak, use a walking belt or two nursing staff members when ambulating the client.
6. encourage the client to wear glasses and use walking aids when ambulating.
7. if the client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as rising slowly, remaining seated several minutes before standing, flexing feet upward several times while sitting, gsitting down immediately if feeling dizzy, and trying to have someone present when standing.
[color=#3366ff]how will you evaluate this and when would you know you need to make a "change in plan"?
short term goal in 2 weeks, patient will be able to perform daily exercises to improve overall le strength and rom
1. consult with physician for a safety evaluation before beginning an exercise program; if program is approved, begin preparing for exercises.
2. schedule physical therapy sessions to have specialist teach exercises that are relevant to the patient.
3. help patient practice rom everyday at a set schedule.
4. provide emotional support to encourage patient to keep trying.
5. before activity, observe for and, if possible, treat pain. ensure that the client is not oversedated.
6. obtain any assistive devices needed for activity, such as gait belt, walker, cane, crutches, or wheelchair, before the activity begins.
psychosocial nursing care plan
patient problem: ineffective coping aeb by ssri medication, decreased social interaction r/t incontinence, immobility, feelings of hopelessness.
expected outcome
nursing interventions
evaluation/
change in plan
short term goal in 2 weeks, patient will express realistic self-evaluation and increased sense of self-esteem.[color=#3366ff] did she have "low self esteem"?
1. assess the client's level of depression and physical reactions to hopelessness.
2. treat the patient with courtesy and respect. converse at client's level, providing meaningful conversation while performing care.
3. if irrational thoughts or fears are present, offer the client accurate information and encourage him or her to talk about the meaning of the events contributing to the feelings of distress.
4. encourage the client to use positive self-talk such as, "i can do this one step at a time," "right now i need to breathe and relax," "i don't have to be perfect."
5. provide clients with a means to listen to music of their choice or audiotapes. provide a quiet place and encourage clients to listen for 20 minutes.
6. encourage client to participate in activities scheduled for the day by the facility.
short term goal in 2 weeks, patient will communicate their needs and negotiate with others to meet needs
1. observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation.
2. help the client set realistic goals and identify personal skills and knowledge.
3. encourage the client to make choices and participate in the planning of care and scheduled activities
4. be supportive of coping behaviors; allow the client time to relax. actively listen to complaints and concerns.
5. teach the client to problem solve. have the client define the problem and cause, and list the advantages and disadvantages of the options.
gggggf
htn pvd
katydid_flip
9 Posts
The only book they suggested we have is the NANDA diagnosis book. The small one that has all the diagnoses in it. They never told us about a book that would help us complete the care plans! For awhile I was doing everything from my head....it sucked!