I only got to see my patient for 2 1/2 hours before they were discharged home. This patient had bone spurs removed/rotator cuff repaired. Other diagnosis: IDDM, HTN, asthma, and arthritis. The only labs that were abnormal: bedside glucose from the day of surgery: 255 (90 - 110) and a hematocrit of 0.1 higher than normal. Patient was on PCA pump morphine 1mg/ml. Also, three additional PRN pain meds. Was given a total bed bath due to inability to move that side of body. Able to ambulate nursing their arm in a sling. PRN ice packs on affected shoulder. V/S slightly higher than normal. Temp of 100.4 that went down to 98.4 within 2 hours.

Given 1 hour to write down 10 NDs specific to my patient. Number them in order of priority. Pick out 2 physiological and one psychosocial ND - write care plans for each one; must include ND with R/T statements, clinical data supporting ND, interventions with rationales (at least 5 per ND care plan).

Wanted to use pain as #1, but I was told that instructor said nobody has ever died from pain. Thought about risk for impaired glucose control, but realized that blood glucose of 255 is probably not that unusual for patient (probably NPO, stressed) on the day of surgery. Picked 2 safety and security NDs. Maybe not a good idea?

#1. Impaired skin integrity r/t incisions and tissue trauma from invasive surgical procedure.

Interventions included that diabetics sometimes have more problems with wound healing - may need wound care specialist. Included nutrition with extra protein for healing properties. Exercise for more oxygen capacity for healing. Of course, keep wound clean, dry, and bandaged as ordered. Monitor temp as an indicator of infection.

#2 Impaired physical mobility of shoulder r/t invasive surgical procedure.

Interventions were to give pain med 30 minutes before exercise; go to physical therapy for specific exercises and equipment; allow pt. plenty of time to complete ADLs. Combine activities when possible for less exertion; provide assistance as needed.

Now anxiously awaiting my grade...

Anyone have any ideas?

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. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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

1. 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)
   
2. 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)
   
3. Planning (write measurable goals/outcomes and nursing interventions)
   
4. Implementation (initiate the care plan)
   
5. 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.

So tell me about your patient.......What do they need? What do they c/o?

Thanks for your advice. You gave me a lot of wonderful information, and I really appreciate it! Keep it coming!

It was hard to come up with diagnosis on a patient that I only saw for a couple of hours. I did my best to assess and snoop as quickly asI could. I had to rely on the patient's chart, but could only find a couple of abnormal labs.

I conducted a 10 minute assessment (probably took me longer) on my patient. The only abnormal that I found was an elevated temperature of 100.4. When I checked it 2 hours later, it had gone down to 98.4. I gave my patient a bath because they were in pain or just afraid to move the left arm/shoulder. They were on a PCA pump and reported a pain level of 5 out of 1 -10 scale. I talked to my patient and conversationally tried to find out information without interrogating them. I looked at all of the prescribed meds (mostly diabetic and pain medications; an anti-infective IVPB), looked at all of the labs tests (bedside glucose from the day of surgery: 255 (90 - 110) and a hematocrit of 0.1 higher than normal - only two labs that were abnormal), looked at CT scan and CXR reports - nothing out of the ordinary, read the doctor's reports, and talked to the family. The patient had not had an asthma attack in 4 years. The patient was a thriving family member; others depended on them for transportation and emotional support.

I really wanted to use pain as my #1 diagnosis because that is the one thing that my patient complained about. They were not a complainer really - just reported a 5 out of a 1 - 10 level. But, they vocalized about not being able to take care of things at home. I used that as my psychosocial diagnosis: interrupted family processes r/t hospitalization, invasive surgical procedure, inability to assume normal family functioning.

The diagnosis part was hard with very few abnormals. Ithought that it's possible that their elevated glucose was from being NPO andstress from surgery. So I asked myself, looking at my patient, what is the worst thing that could happen to them right now? I was unable to look under the bandage, but I know there were incisions from the surgery. Even small incisionsin a diabetic patient can be hard to heal due to possibly poor glucose control and poor circulation. So I thought we can enhance healing if we can keep the sugar under control, give good wound care, and provide exercise for more oxygenation to help with circulation and increase nutrients and antibodies to the woundsite. Give proper nutrition - extra protein and vitamins for healing. This is something that needs to be done from the start - not wait until a problem presents itself. Therefore, I came up with: #1. Impaired skin integrity r/t incisions and tissue trauma from invasive surgical procedure.

Now what else is wrong with my patient? I had to give them a bath because they can't/won't move their left arm/shoulder. It is in a sling, but they will need to start moving it. What can I do? They are on pain medication, so if I give them their pain meds and keep it at a comfortable level, they maybe able to do more - even exercise. But, they are being discharged home, so they may need to go to physical therapy where there is specific equipment and therapists to teach them exercise specific to their problem. At home, instead of doing ADLs for the patient, the family can allow the patient more time to complete the ADLs and even combine activities - just provide assistance if needed. Thus, #2 Impaired physical mobility of shoulder r/t invasive surgical procedure.

I wondered if anyone agreed with me. You are right, I did not give a lot of assessment data on my patient, but I really did not have much to go on. Just a few hours to make snap decisions... I would appreciate more advice...

Do you have a nursing diagnosis book? They are imperative to making your care plans. I use Ackley: Nursing Diagnosis Handbook, 9th Edition.

There is plenty here to make a care plan. What are the possible complications from this procedure? What are the complications of anesthesia? What education will your patient need to go home? (deficient knowledge) You said he is concerned about ADL's and personal care....There is always the possibility of poor glucose control when the diabetic system is under stress. Pain is always and issue for surgical patients.

his patient had bone spurs removed/rotator cuff repaired. Other diagnosis: IDDM, HTN, asthma, and arthritis. The only labs that were abnormal: bedside glucose from the day of surgery: 255 (90 – 110) and a hematocrit of 0.1 higher than normal. Patient was on PCA pump morphine 1mg/ml. Also, three additional PRN pain meds. Was given a total bed bath due to inability to move that side of body. Able to ambulate nursing their arm in a sling. PRN ice packs on affected shoulder. V/S slightly higher than normal. Temp of 100.4 that went down to 98.4 within 2 hours.

Just with this......Here are a few ND that come to mind.....

Risk for Infection

Deficient Knowledge (specify)

Impaired physical Mobility

Acute Pain

Bathing Self-Care deficit

Risk for unstable blood Glucose level

Again allow the patient drive the diagnosis.

You prioritize according to Maslows Hierarchy of needs.......

Maslows hierarchy of needs. maslow's hierarchy of needs - enotes.com Virginia Henderson's need theory. at risk is never the top priority unless this is hypothetical and there is not a real patient.

Maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

• self-actualization – e.g. morality, creativity, problem solving.
  
• esteem – e.g. confidence, self-esteem, achievement, respect.
  
• belongingness – e.g. love, friendship, intimacy, family.
  
• safety – e.g. security of environment, employment, resources, health, property.
  
• physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis.
  

assumptions

• Maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.
  

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

• the needs Maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
  
• growth needs are the highest level, which is self-actualization, or the self-fulfillment.
  
• Maslow suggested that only two percent of the people in the world achieve self actualization. e.g. Abraham Lincoln, Thomas Jefferson, Albert Einstein, Eleanor Roosevelt.
  
• self actualized people were reality and problem centered.
  
• they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
  
• they tended to be spontaneous and simple.
  

application in nursing

• maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.
  

so pain is a high priority.