[shannon88]

Originally Posted by aviator411

Shannon,

Hard to believe this book would be that helpful; it was last published in Mar of 95. Next edition not due until Jan 08. Wish I could look at a copy.

Aviator,
I'm not sure where you got your information from. This book, published by Pearson Prentice hall, was last published in 2005. I'm eagerly anticipating their newest edition, available in 2009. And it is extremely helpful to both my classmates and I. Our nursing instructors highly recommend it.

Thanks,though

[Rage]

first and foremost above all else is the need to assess.........it is the first step in the nursing process known as ADPIE....but then you assess every time you meet someone, which is the reason that communication is 90% non-verbal........you ARE assessing. In the nursing process you have to focus the assessment process to the prevailing aspects that are affecting your patient. Assessment procedures are both formal and informal, visual and tactile. I'm sure your nursing books are filled with most of the assessments that are done for different situations.........in clinicals you get a cardex on the patients and a update from the previous shift nurse as to the current condition of your patient. Then you go and assess your patient to draw your own conclusions as to how that patient is responding to treatment, conditions, medications, procedures, etc.........
But now that you have gotten your assessment criteria and you have the medical diagnosis from the cardex, what do you do? Based on medical diagnosis and your assessments you create a "nursing diagnosis" that reflects real/potential problems your patient is/could face. ARF: medical------Excess fluid volume: Nursing / Decreased Cardiac Output: Nursing / Risk for Infection: nursing.........etc.

Now you need the "P" in ADPIE and this is where most students have the difficulties...........everything else can be found in books including the interventions, but most students want to include aspects in their plans that aren't the same as everyone has in their plans..........(Read as well worn care plans). Understanding this (Since I'm a graduating student who has receiving excellent on all of my care plans) pm me and I'll let you know the site I used to create my care plans.........
Understand that what is good in school isn't necessarily what is good in the real world............so where as I humbly bow to those with many years of experience (yes I have shown my care plans to experienced nurses in clinical and got the raised eyebrows, but still made an excellent in school), in school it is a different ballgame. Not all schools but most that I have encountered via the students.

[juli44]

We were given a care plan example - a plant with droopy leaves. The way it simplified the knowledge worked for me. When ever I get stuck I go back to the plant. My suggestion is to make a simplified care plan and have it checked by your teacher and use it as a reference.

[trepinCT]

our "related to" is the etiology and has to be something we can change or improve..we cannot say r/t surgery because we cannot change the surgery..

[mabton8]

Does anyone have any ideas as to a nursing diagnosis for hypotension?

[Daytonite]

Hi, mabton8, and welcome to allnurses!

I say this so much that I wonder if it is even posted on this thread: You cannot determine a patient's nursing diagnosis from his/her medical diagnosis. Burn that statement into your brains. It would be like a doctor asking you if you have any ideas as to a medical diagnosis for a patient who has Ineffective Tissue Perfusion. You'd look at the doctor and wonder what was wrong with his thinking.

When you are writing a care plan and determining the patient's problems (labeling them with a nursing diagnosis) you must follow the nursing process. The nursing process is the problem solving process that we use, plain and simple. There are plenty of posts on this thread that go through those 5 steps and you should read the posts on this thread to learn about them if you do not know them already.

The most important step is the first one--Assessment. From your assessment of the patient which includes a thorough review of the patient's medical record, an interview of the patient about their health and medical history and your own physical examination you learn what their problems and signs and symptoms of their health are. It is these signs and symptoms that will give you any ideas as to nursing diagnoses your patient has, not necessarily the fact that he/she has a medical diagnosis of hypotension. You will use these signs and symptoms and compare them to signs and symptoms listed under the various nursing diagnoses to find a match for your patient. Every nursing diagnosis has a list signs and symptoms (they are called defining characteristics) that goes with it. You need a nursing diagnosis reference book of some sort in order to correctly make these matches. This patient needs to be assessed for the ability to achieve daily ADLs and that is not something that is part of the signs and symptoms of the medical diagnosis of hypotension. This patient may have other problems that don't even relate to hypotension that you would not know about without performing your own assessment. In fact, the remainder of your care plan is going to be nearly entirely based on your assessment information--not on the fact that the patient has a medical diagnosis of hypotension although the hypotension may affect some judgments that you will make about the etiology of some of the patient's problems.

So, the question you should be asking is "any ideas as to a nursing diagnosis for a patient that has these signs and symptoms. . .?

If you are still having problems determining your nursing diagnoses, post a question along with your patient's signs and symptoms in either the Nursing Student Assistance Forum (http://allnurses.com/forums/f205/) or the General Nursing Discussion Forum and you will get help.(http://allnurses.com/forums/f50/)

[jonndell]

Hi! I'm new to this site and I came across your post and I'm actually creating a care plan similar to the one you just posted. My instructor told us to provide 2 short term goals and 1 long term goal for each nursing diagnosis. I see that you have posted a long term goal for this nursing diagnosis, but what can you suggest as short term goals for this?

NDx:
Impared skin intergity r/t decreased mobility (bed bound), AEB moist warm reddened areas on bilateral buttocks

[Daytonite]

Originally Posted by jonndell

Hi! I'm new to this site and I came across your post and I'm actually creating a care plan similar to the one you just posted. My instructor told us to provide 2 short term goals and 1 long term goal for each nursing diagnosis. I see that you have posted a long term goal for this nursing diagnosis, but what can you suggest as short term goals for this?

NDx:
Impared skin intergity r/t decreased mobility (bed bound), AEB moist warm reddened areas on bilateral buttocks

Hi, jonndell, and welcome to allnurses!

Goals are a result of planned nursing interventions. We know nothing about the nursing interventions you have planned for your patient so how can we suggest short term goals for him? Your goals for any patient are directly related to and must correlated with the specific nursing interventions that you have determined in your care plan for your patient. Each care plan is specific to each patient's needs.

Goal statements have four components:

1. A behavior
   • this is the desired patient response/action you expect to see/hear as a direct result of your nursing interventions.
   • you must be able to observe the behavior
2. It is measurable
   • criteria that identifies exactly what you are measuring in terms of
     • how much
     • how long
     • how far
     • on what scale you are using
3. Sets the conditions under which the behavior should occur
   • such conditions as
     • when
     • how frequently
   • take into account the patient's overall state of health (this requires knowing the pathophysiology of their disease process)
   • take into account the patient's ability to meet the goals you are recommending
   • it is a good idea to get the patient's agreement to meet the intended goal so both the nurse and the patient are working toward the same goal
4. have a realistic time frame for completing the goal
   • long-term goals usually take weeks or months
   • short-term goals can take as little time as a day
   • it all depends on knowing what your nursing interventions are designed to do and what you believe your patient is capable of doing.

You can find care plan information on this other sticky thread of allnurses as well:

• http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)

You should also start a new thread in the Nursing Student Assistance Forum (http://allnurses.com/forums/f205/) to get specific help with questions about your care plan where I will see it.

This thread also has information on writing goal statements:
http://allnurses.com/forums/f205/how-write-nursing-goal-312157.html#post2919595 - How to write a nursing GOAL?

[mitchdlbartolome]

i have some of my compilations of care plans here but it is based under Philippine settings. You can check it out and see if it helps.

http://nursingcrib.com/category/nursing-care-plan/

[debbie54]

wow!!