[Daytonite]

Here is a link to the page that contains links to the 42 nursing diagnoses that are currently in the Elsevier care plan constructor companion website for Nursing Care Plans: Nursing Diagnosis and Intervention, 6th edition, by Meg Gulanick and Judith L. Myers. Each of these pages contains the NANDA definition, outcomes, and nursing interventions.

• http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm

In addition, there are three more nursing diagnosis pages that you can also link into:

• http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=06 - Risk for Imbalanced Body Temperature
• http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=07 - Bowel Incontinence
• http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=56 - Impaired Urinary Elimination (has an explanation about it, but no other information)

[skyranger]

Here is a care plan software for PC
This is fully functional demo version - easy to use and saves time.
Can be downloaded from www.carescribble.com

[Daytonite]

Hi, negrita!

The care plan process always starts with the data that you have collected (Step #1 of the nursing process). From that data you make a list of the abnormal, or the things you discovered that are not normal. These things become the symptoms, or patient's defining characteristics (NANDA language), that will help you to determine that Impaired Skin Integrity is the correct nursing diagnosis to be using (Step #2 of the nursing process).

Please list these abnormal symptoms for me, so I can help you with this.

Welcome to allnurses!

[Daytonite]

Originally Posted by negrita

Ct had a femoral/poplital bypass. client past helath history is HTN And DVT.

I don't think you are understanding me. What you have responded with are medical diagnoses. This is of no help. A care plan addresses the problems your patient has. These problems are based upon abnormal assessment data, not medical diagnoses. For example, since the patient had a femoral/popliteal bypass I would assume that there is an incision. Are there any problems with the incision? Does the patient currently have any open skin ulcers on the affected lower limb? If so, what is the description of them? Is there any pedal or lower leg edema? Any changes in sensation? Did you assess the patient's ability to perform ADLs? Can the patient walk? The answers to these questions are potential abnormal assessment data that need to be known in order to design and work nursing interventions into a care plan. While Impaired Skin Integrity is one possible diagnosis there is a possibility based on the little bit of medical diagnosis information you have supplied that the patient might also have Ineffective Tissue Perfusion, peripheral and Decreased Cardiac Output. However, I can't verify that without knowing your assessment data. Is this a real patient or a non-existent subject of a case study assigned by your instructor?

[nursey23]

i would like to but we were just given this situation :

patient name (age, religion, location) was admitted at the hospital due to multiple fracture and lacerations after an mva. 1 hr pta, pt was with her bf driving along the highway at 150 kph when suddenly, her bf lost control of the motorbike.

patient was thrown 15 m away. residents near the accident site brought them to the er. her bf was pronounced doa while patient was rushed to or. upon initial visit to patient, you observed that both legs have casts. multiple lacerations and contussions are observed on her fae and all over her body. patient doesnt want to eat or talk to anyone. she wasnt able to take anything by mouth since her operation. V/S revealed

t - 38.6
p - 95 bpm
r - 19 cpm
bp - 130/90

for certain, the patient has the following probs - she cant move, she won't eat (im uncertain as to whether how long it has been between her operation and the 'today' of the situation and whether she has an IV or not and whether this would be enough for the moment to sustain her nutritional needs) and she has a fever.

given that situation, we are supposed to come up with a care plan and a discharge plan.

[Daytonite]

In your original post you asked for help with the nursing diagnoses and which ones should be listed (focused upon) first.

This patient has sustained a major trauma, has had surgery and suffered a major personal loss with the death of her boyfriend. The first step in writing a care plan is to assess your patient. Assessment data has been given to you in the information provided. From the scenario, I have isolated the following abnormal data (problems):

• multiple fractures
• multiple lacerations
• multiple contusions on her face and body
• both legs have casts
• patient doesn't want to talk to anyone (assume this is an indication of her grief over the death of her boyfriend)
• wasn't able to take anything by mouth since her operation (this could be due to nausea from the anesthesia, an unknown injury in the accident you weren't told about, or grief over the loss of her boyfriend)
• Temperature of 38.6 degrees (elevated)
• Pulse 95
• B/P 130/90 (slightly elevated)
• pain [I've added this because it's reasonable to anticipate that the patient will have pain because of her injuries]

In Step 2 of the care plan process you need to match these problems, or symptoms, with defining characteristics of nursing diagnoses that will apply to this patient. To do that you need your NANDA nursing diagnosis reference book to confirm that you are matching these items to the correct nursing diagnoses. These are nursing diagnoses that will fit with these symptoms in the sequence of importance:

• Imbalanced Nutrition: less than body requirement R/T lack of interest in food AEB wasn't able to take anything by mouth since her operation
• Impaired Tissue Integrity R/T traumatic injuries AEB multiple lacerations and multiple contusions on her face and body
• Hyperthermia R/T trauma AEB Temperature of 38.6 degrees
• Impaired Physical Mobility R/T immobilization of legs AEB multiple fractures of bones with casts on both legs
• Acute Pain R/T traumatic injuries AEB elevated blood pressure and heart rate [patient would also be reporting she was having pain]
• Grieving R/T death of boyfriend AEB patient doesn't want to talk to anyone
• Risk for Infection R/T traumatic tissue injuries
• Risk for Injury R/T immobility [thinking of the potential to develop a DVT here]

Now, that all the problems (defining characteristics) have been divided up and placed with nursing diagnoses, the next step is to develop goals and nursing interventions for them. So, you need to look in your nursing textbooks to find nursing care for:

• ways to encourage the patient to eat
• lacerations and contusions
• care of a patient with a fever
• an extremity with a cast, care of the cast
• interventions for the patient having pain
• how to help the patient deal with her grieving at the loss of her boyfriend and the emotional burden she has at this time
• actions you will need to take to avoid the patient developing an infection of any of her wounds
• actions you will need to take to help prevent the development of a DVT in her legs that have casts on them

Since this patient also underwent surgery a few other potential problems should be observed for and prevented:

• breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
• urinary retention
• constipation
• nausea/vomiting (due to paralytic ileus)

If you like, you can work them into the nursing diagnoses as other "Risk for" diagnoses.

[Daytonite]

Can someone help me to create nursing diagnoses for asthmatic patients?

The first step in choosing a nursing diagnosis involves assessing the patient. Any nursing diagnosis is ALWAYS based upon the signs and symptoms the patient is having. These signs and symptoms are abnormal assessment items. Depending on how thorough your assessment of the patient is will determine how well your care plan is going to attend to the patient's problems.

With asthma, the patient is, in general, going to have these symptoms in order as an asthma attack worsens:

• hacking, non-productive cough (due to bronchial edema)
• restlessness
• diaphoresis
• only able to speak in short, broken phrases
• eventually the cough become productive of frothy, clear sputum
• breathlessness
• chest tightness
• dyspnea (shortness of breath)
• use of accessory respiratory muscles
• hyperresonance
• tachycardia
• some mild systolic hypertension
• inspiratory and expiratory wheezes
• crackles (as spasm and obstruction worsen)
• prolonged expiratory phase of respiration (due to bronchospasm)
• mucusal edema
• mucus plugging with mucus trapped behind airways that are narrowed or occluded
• diminished breath sounds
• cyanosis, lethargy, confusion and hypoxemia (as the patient proceeds to status asthmaticus or respiratory failure)

Based upon one or more of these above symptoms being present, nursing diagnoses that would be appropriate to use, in priority order, would be:

• Gas Exchange (abnormal skin color, confusion, cyanosis, diaphoresis, shortness of breath, hypoxemia, tachycardia, abnormal blood gases) - this diagnosis is generally used when there is hypoxia, hypoxemia or the patient is getting close to it
• Ineffective Breathing Pattern (alterations in the depth of breathing, shortness of breath, orthopnea, prolonged expiratory phase of expiration, use of accessory respiratory muscles to breathe) - the act of breathing is not providing enough air
• Ineffective Airway Clearance (any kind of cough, ineffective cough, any kind of adventitious breath sounds, any kind of changes in the rate or rhythm of the respirations, difficulty speaking due to breathing Impaired, excessive sputum production) - this diagnosis is when the person is having difficulty clearing secretions from the respiratory passages in order to maintain a clear airway
• Fear (fear of suffocation or death) - threats to the self that the patient recognizes as dangerous
• Anxiety (obsessive tinkering with oxygen equipment, over attention to medication, treatment, physical symptoms) - warnings of impending danger causing patient to take measures to deal with threats

Examples of a nursing diagnostic statements using the above nursing diagnoses for an asthmatic patient might be:

• Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by cyanosis, lethargy, confusion and hypoxemia
• Ineffective Breathing Pattern related to fatigue as evidenced by prolonged expiratory phase of respiration, shortness of breath and the use of accessory respiratory muscles to breathe.
• Ineffective Airway Clearance related to airway spasm as evidenced by diminished breath sounds with inspiratory and expiratory wheezes and shortness of breath.
• Fear related to threat of suffocation as evidenced by increased excitement and statements of "I'm not getting enough air!"
• Anxiety related to fear of suffocation as evidence by patient constantly checking to make sure oxygen tubing is correctly positioned and asking what the setting of the oxygen flow is.

It would be very useful to have a book of nursing diagnoses or care plans that include the NANDA definitions, defining characteristics and related factors since NANDA is very specific about how each of the nursing diagnoses should be used.

[Daytonite]

There is a "sticky" thread on the Nursing Student Assistance Forum specifically on care maps (concept maps) as care plans.

• http://allnurses.com/forums/f205/care-maps-225330.html - Care Maps (in Nursing Student Assistance Forum)

In that thread are links to a couple of sample concept maps that some other students posted on allnurses so you can see what a completed one looks like. Did your instructors give you a specific format to use? There is one book on nursing concept mapping that I know of that you can buy

• Concept Mapping: A Critical-Thinking Approach to Care Planning by Pamela McHugh Schuster, published by F.A. Davis and costs about $26.

I have a copy of it and it explains in more depth what is on the cord.org website that two others have already given you a link to. The allnurses thread I gave you above has a link to an online nursing concept map constructor.

If you are still having trouble with this assignment, post to this thread the problems you are having, or you can PM me.

A concept map is just a visual representation of the critical thinking process you are going through in creating your care plan. All care plans, however follow the nursing process and begin with the assessment that you have made of your patient. The abnormal assessment data forms the foundation of everything you are going to end up doing for the patient. With a concept map you are going to be separating and listing these things out into boxes around a main central box that contains the admission diagnosis of the patient (the only time you actually use a medical diagnosis on this kind of care plan).

THE STEPS OF THE NURSING PROCESS (WRITTEN CARE PLAN) Assessment (collect data) Nursing Diagnosis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use) Planning (write measurable goals/outcomes and nursing interventions) Implementation (initiate the care plan) Evaluation (determine if goals/outcomes have been met)

Here are two other "stickies" on the nursing forums to help you with care planning.

• http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)
• http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum)

Please understand that a concept map is just a different physical presentation of a care plan that was designed to help you learn the critical thinking involved in putting all the needed elements together. You still have to perform all the above 5 steps I just listed. The most important steps in getting a care plan started are Steps 1, 2, and 3 and where you will spend the most time.

[Daytonite]

Hi, newstart08!

First of all, congratulations on starting your RN bridge program.

Secondly, to start you off with this whole process of care planning I'm going to give you the links to three "sticky" threads on nursing student forums that you should read over when you get a chance because most of the information I tell students about care plans is repeated there and you can find it very conveniently

• http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)
• http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum)
• http://allnurses.com/forums/f205/care-maps-225330.html - Care Maps (in Nursing Student Assistance Forum)

Care plans, no matter in what format they are eventually committed to paper, follow the nursing process. If you don't learn another thing from your RN program, this is the one concept that you MUST learn:

THE STEPS OF THE NURSING PROCESS (WRITTEN CARE PLAN)

1. Assessment (collect data)
2. Nursing Diagnosis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis 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)

Before you can even decide on any nursing diagnoses you need to go through Step #1 which is collect your assessment data:

A 60 y.o. female with a hx of ASHD and HTN. Brought to the ED by ambulance. She is c/o nausea, anorexia, blurred vision. She is alert and orientated; although her daughter states that she has had periods of confusion over the last several days. The client explains that she is currently under her MD's care for episodes of atrial fibrillation and atrial flutter that began about 1 week ago. Home meds include: Digoxin 0.125 mg daily, as well as Quinidine Sulfate and Catapress. The cardiac monitor reveals atrial fibrillation with a ventricular rate of 180 bpm.

I've colored and highlighted the abnormal assessment data. It is the abnormal assessment data that becomes the most important in determining the nursing diagnoses you will use--NOT THE MEDICAL DIAGNOSIS. The medical diagnoses become important in your critical thinking process and looking at the underlying pathophysiology of what might be going on with your patient, but does not particularly affect your choice of nursing diagnoses. You need to do a little investigatory work here first. If this were a real patient I would advise you to look up the signs and symptoms of ASHD, HTN, atrial fibrillation and atrial flutter to see if you missed any of them when doing your patient's assessment. You should look them up now anyway to learn about them and to confirm what I'm about to tell you. Also, look up these three drugs, what they are for and their side effects.

• the blurred vision may be a symptom of her hypertension
• a complication of atrial fibrillation is TIAs and strokes
  • symptoms of a stroke can include a change in the person' level of consciousness and sensory losses (as in visual disturbances)
• nausea can occur with a lot of conditions but to keep to the scenario at hand, it occurs in arrhythmias, right sided heart failure (why is this patient on Digoxin?), myocardial infarctions and as a side effect of some medications (Catapres?)
• one of the things that is happening when a heart is in tachycardia (the heart rate of 180) is that the heart is attempting to get more oxygen to the body's tissues. Because each of these beats contains less blood than normal. Less blood=less oxygen going to the tissues. The affect of this is that it decreases cardiac output (less blood being pumped) and, therefore, cardiac and peripheral perfusion (less oxygen) with the resulting symptoms of dizziness and decreased levels of consciousness (perfusion to the brain)
• anorexia can be a side effect of drug therapy
• sometimes you won't be able to discover why the patient is having the symptoms they are having because there is just not enough data.

So, the patient's symptoms that you have to work with are:

• tachycardia
• nausea
• blurred vision
• periods of confusion over the last several days

In Step #2 you want to match these abnormal assessment items to likely nursing diagnoses. This requires that you have some kind of NANDA reference to look at. It is important to be able to refer to the defining characteristics (symptoms) of each nursing diagnosis you are considering using. You also need to look at the definition of each nursing diagnosis you use because it tells you what the purpose is that the particular diagnosis is aiming to target as the patient's problem. A NANDA reference is also going to give you the related factors (you will call them R/T items in your nursing diagnostic statement) so you don't have to be trying to fathom these things out yourself. NANDA's already done it for you.

There are 4 potential nursing diagnoses here based solely on the information provided by the scenario. I am going to list them in order of priority (by Maslow's Hierarchy of Needs). Keep in mind that this is my interpretation of the scenario. Your instructor might have different ideas based of what you have been getting lectures over. If you are allowed to pull in information from investigating the signs and symptoms of ASHD, HTN, atrial fibrillation and atrial flutter there might be more nursing diagnoses and some of your nursing diagnostic statements would become greatly expanded with much more assessment data. I've also linked you to nursing diagnosis pages on some of the online care plan constructors so you can see the NANDA information as I'm seeing it from my reference books.

1. Decreased Cardiac Output R/T altered heart rate and rhythm AEB a ventricular heart rate of 180 beats per minute and atrial fibrillation Decreased Cardiac output http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=09
2. Nausea R/T drug therapy AEB patient report of nausea and anorexia Nausea
3. Disturbed Sensory Perception, visual R/T altered sensory reception AEB patient report of blurred vision Disturbed Sensory perception specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=46
4. Risk for Injury R/T tissue hypoxia and/or a side effect of medication [this covers the confusion] Risk for Injury

If you look at these diagnostic statements very carefully you will see that all the information that follows the "AEB" part of each statement is actually the abnormal assessment information that I highlighted in red from your original scenario. When you move on to Step #3 which is to write measurable goals/outcomes and nursing interventions, it is these abnormal assessment items that you address. You will also notice that the "R/T" part of each statement is an etiology, or what you best perceive to be the cause, of the patient's AEBs in keeping with the spirit of that nursing diagnosis.

Just so you don't think I'm pulling stuff out of a hat, here are the books I used to help me determine the above:

• NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 published by NANDA International
• Nursing Diagnosis Handbook: A Guide to Planning Care, 7th Edition, by Betty J. Ackley and Gail B. Ladwig
• Signs & Symptoms: A 2-in-1 Reference for Nurses by Springhouse, Springhouse Publishing Company Staff
• 2007 Mosby's Nursing Drug Reference, 20th edition, from Mosby, Inc.

I wanted to make one comment. I know you posted this same question on another forum and someone responded to you with some possible nursing diagnoses to use. Specifically,

Decreased tissue perfusion R/T decreased cardiac output & AEB periods of confusion

is wrong, wrong, wrong.

1. The correct diagnosis is Ineffective Tissue Perfusion and it MUST be specified as to the system of the body involved Ineffective Tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral
2. This diagnosis covers all tissues EXCEPT the heart specifically.
3. For decreased tissue perfusion of the heart itself you must use Decreased Cardiac Output.
4. If you refer to a NANDA reference or any careplan book that lists the related factors for this diagnosis of Ineffective Tissue Perfusion you will not find decreased cardiac output listed as a related cause. It is because decreased cardiac output has been put into it's own nursing diagnosis.

Where the perfusion and/or circulation of the heart, the organ, is the underlying problem you will ALWAYS, ALWAYS, ALWAYS use the nursing diagnosis of Decreased Cardiac Output. Therefore, it is imperative that you have a good understanding of the terms used by NANDA in this diagnosis: preload, afterload, conductility.

If you are still having trouble with this, let me know.

Welcome to allnurses!

[cutegurl]

anyone there who could help me to make a Nursing Care Plan about vaginal bleeding and threatened abortion. i dont have any books about Care Plans.