Writing a Nursing Care Plan on a Hypothetical Patient

audie88 · Oct 8, 2013

Hi,

Im a junior nursing student and I still have trouble with nursing dx. From what you wrote it sounds like a good nursing dx would be either Impaired gas exchange bc of the sob or Impaired activity intolerance bc of the sob with activity. There are tons more that you can come up with but those sound like the priority. As far as intervention you want them to be pt. specific and measurable so with impaired gas exchange you could say assess o2 sat q2h, administer breathing tx per orders things like that. I hope this helps. If you have any other questions let me know and ill try to help.

Esme12, ASN, BSN, RN · Oct 8, 2013

Is this a care plan in general or just a care plan with a wellness diagnosis? What lung condition can give you "hollow resonance" upon auscultation? or percussion.

I would look to the obvious.....what behavior does the patient have that there is a TON of information on?

Smoker on average 10 cigarettes/week,

Readiness for enhanced self-Health management R/T .....pt expresses desire to improve breathing capacity.

ChloeTheWise · Oct 8, 2013

Sorry-- I was under the impression that it had to be a wellness diagnosis, but I discovered today that I had the wrong understanding. The diagnosis can be anything. Current, at risk for, or wellness.

So with that in mind, "Impaired tissue perfusion r/t smoking AEB S.O.B with activity" might be an option... is that a place to start? Is there anything wrong with this diagnosis?

Esme12, ASN, BSN, RN · Oct 8, 2013

NO.....you are picking the diagnosis and trying to fit the patient into it.

Make a list of problems...this is hard when you don't have a patient to look at. Nursing diagnosis is based (or supposed to be based) on assessment....what the patient needs.

Esme12, ASN, BSN, RN · Oct 8, 2013

Now......

Chief complaint: S.O.B. and cough with activity
Health History: Smoker on average 10 cigarettes/week, Currently has a productive cough with green phlegm.
Objective findings were all "normal" for this hypothetical patient. Thoracic cage symmetrical, Respiratory rate 15 breaths/minute and even, skin pink and intact, alert and oriented x3... Clear in all lung fields, no adventitious sounds, hollow resonance, no lumps, and trachea is midline to the body...

What is hollow resonance......LUNG RESONANCE

The lung is filled with air (99% of lung is air), hence percussion of it gives a resonance. This step helps identify areas of lung devoid of air.

Keep the middle finger firmly over the chest wall along intercostal space and tap chest over it using middle finger of opposite hand. The movement of tapping should come from the wrist. Tap 2-3 times in a row. Listen and feel the resonance. Percuss the chest all around. Stand back, have patient cross arms to shoulder. This maneuver will wing the scapula and expose the posterior thorax. Percuss starting from top to bottom of thorax on either side. Compare the resonance by percussing the corresponding spaces alternately. Stand on one side of the patient and with the flat of your hand, tap the chest from top to bottom and from side to side to compare. Then, have the patient keep their hands over head and percuss axilla. Then move to the front and percuss anterior chest, clavicles and supraclavicular space.

Normal: Appreciate the dullness of the left anterior chest die to heart and right lower chest due to liver. Note the hyper-resonance of the left lower anterior chest due to air filled stomach. Normally, the rest of the lung fields are resonant.

Abnormal: Decreased or increased resonance is abnormal.
Increased resonances can be noted either due to lung distention as seen in asthma, emphysema, pneumothorax or bullous disease.

Untitled Document

So this patient probably has a ling pathology of COPD/emphysema with a history of smoking and cough in absence of fever.

Now what problems could your patient have?

S.O.B. and cough with activity .....Currently has a productive cough with green phlegm.

What care plan book do you have?

Esme12, ASN, BSN, RN · Oct 8, 2013

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at).

The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

ChloeTheWise · Oct 8, 2013

I have Ackley and Ladwig Nursing Diagnosis Handbook, Ninth Edition. With the consideration that my patient has no history of COPD or lung disease, I am really struggling to understand how I could make a care plan focused on that. The assessment that I did revealed no issues with ADLs, no history, no abnormal anything, in essence. All I have to focus on is the smoking, cough with green phlegm, and shortness of breath with activity (when walking from upstairs to downstairs, and when trying to exercise) and the "hollow resonance" I was talking about was not intended to mean that it was abnormal-- what I meant by that is the normal sound the lungs should sound in response to percussion. Maybe I worded that wrong. So, considering ADPIE, all those things I just explained were my "A" for Assessment. Her main concern was the shortness of breath; my main concern was the phlegm being green which indicates infection, but she doesn't have any history of this, so that is why I am stuck. I am concerned about possible infection as well as her airway (considering her ABC's)... If I'm not making sense please let me know and I will try to expand on it!!

Esme12, ASN, BSN, RN · Oct 8, 2013

now each diagnosis you use must have ...proof that it exists. Unfortunately, this scenario give you much information....

Chief complaint: S.O.B. and cough with activity
Health History: Smoker on average 10 cigarettes/week, Currently has a productive cough with green phlegm.

Ok...now what nursing diagnosis would apply here......

Activity Intolerance: describes this as........Abnormal blood pressure response to activity; abnormal heart rate response to activity; EKG changes reflecting arrhythmias; EKG changes reflecting ischemia; exertional discomfort; exertional dyspnea; verbal report of fatigue; verbal report of weakness

Ineffective Airway Clearance...is defined as Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway as evidenced as.....Absent cough; adventitious breath sounds (rales, crackles, rhonchi, wheezes); changes in respiratory rate and rhythm; cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum; orthopnea; restlessness; wide-eyed

Environmental

Secondhand smoke; smoke inhalation; smoking

Obstructed Airway

Airway spasm; excessive mucus; exudate in the alveoli; foreign body in airway; presence of artificial airway; retained secretions; secretions in the bronchi

Physiological

Allergic airways; asthma; COPD; hyperplasia of the bronchial walls; infection; neuromuscular dysfunction

Ineffective Self-Health Management: Pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals

So for you nursing diagnosis you need to have patient behaviors/symptoms/labs to support what you see. Another contributor to here Grn Tea....says.....

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."
("Related to" means "caused by," not something else.)
To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students.

ChloeTheWise · Oct 8, 2013

I think my patient has Ineffective Airway Clearance caused by excessive sputum. I can see that the airway clearance is an issue due to the patient's chief complaint of dyspnea upon exertion.

Ineffective Airway Clearance r/t excessive sputum production AEB dyspnea upon exertion

ChloeTheWise · Oct 8, 2013

oh.... wait a second, the r/t in the book would have to be the environmental factor of smoking, right? So....

Ineffective Airway Clearance r/t smoking AEB excessive sputum production and dyspnea upon exertion?

Esme12, ASN, BSN, RN · Oct 9, 2013

there you go!!!!