first of all, the gulanik website you posted above is a constructor. it has approximately 45 nursing diagnosis pages on it from the book,
nursing care plans: nursing diagnosis and intervention
, 6th edition, by meg gulanick and judith l. myers. it is not going to suggest nursing diagnoses for medical diseases that the patient has. doesn't work that way. you need to know what nursing diagnoses you want to use. you input information and the constructor will format and print it out for you--that is all it does.
a care map is a type of care plan that is presented in a graphic form. the link to the sticky thread that jadu1106
gave you has information on it about concept maps, what they are and there are several examples of student care maps that you can look at to see how they are done.
, a care plan whether it is presented as a chart, concept map or critical pathway is still developed the same way--by using the nursing process. i talk about writing a care plan and the nursing process all the time. you can read about it on this sticky thread: http://allnurses.com/forums/f50/help...ns-286986.html
- assistance - help with care plans
(in the general nursing student discussion forum). it's pretty much the same as i am about to tell you now.
the steps of the nursing process with regard to care plan writing are:
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms, complications 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)
your project began when you received your two medical diagnoses. you need to begin with step #1, assessment. this activity includes:
- doing a physical assessment of the patient - you can't reasonably do this, can you because this is a non-existent patient? read on.
- assessing the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease - you can't reasonably do this either, can you because this is a non-existent patient? read on.
- collecting data from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians - another ditto
- know the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it. - aha! here's something you can do! take each of your two diagnoses separately and look up all this different information. then, after you've done that think about what you would find if this was a real patient and you were doing a physical assessment. what signs and symptoms would you find? what kind of problems with performing their adls might the person with those disease conditions have? what complications could happen to them, and what are the signs and symptoms of them? list all this abnormal data because you are going to need it for step #2 of the nursing process.
to help you find information about these medical conditions you can use the websites listed on this sticky thread:
- medical disease information/treatment/procedures/test reference websites
you move on to step #2 which involves determining what the person's nursing problems are and attaching labels (nursing diagnoses) to them. you have to know what the abnormal assessment data (or symptoms) are first before you can pick any nursing diagnosis.
think about this for a minute. does a doctor just pick a medical diagnosis out of the air? he absolutely does not! just walk up to any doctor and say, "hey, doc, my back has been killing me lately. can you tell me what's wrong?" the doctor is going to ask you some questions, examine you and probably order some tests. that is how he is going to assess the situation (the medical version of step #1 of the medical decision making process). next, he is going to look at the data that he collected--specifically, the data that was not normal
--and use it upon which to base a medical decision, or medical diagnosis (the medical version of step #2 of the medical decision making process).
our nursing equivalent to diagnosing is step #2 of the nursing process. we take the abnormal data we collected during our assessment activities and use it to determine a nursing diagnosis. every nursing diagnosis has a list of criteria (signs and symptoms--nanda calls them defining characteristics) and your patient must have at least one or more of those in order for you to assign that diagnosis to the patient.
you also need to read the definition of the diagnosis that nanda has provided since the definition gives you a much clearer description of the problem. the 3 and 4 word nursing diagnosis labels are just that--short hand labels. when you are first learning to diagnose you need to use a nursing diagnosis reference to make sure you are diagnosing correctly. there are a number of ways to acquire this information.
- your instructors might have given it to you.
- you can purchase it directly from nanda.
- nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- there are two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free (you've already discovered one of them):
you also need to have 4 nursing interventions and 4 rationales. nursing interventions are based upon those abnormal data items, or defining characteristics that are evidentiary proof that the nursing problem (nursing diagnosis) exists in the first place. treat those, alter those, and you are doing something about the problem because they are intimately linked to the existence of the problem
. rationales are merely the nursing principles underlying why a nursing intervention is going to work. when i was in nursing school our nursing rationales had to be referenced by book, author and page number. you are going to find these in nursing textbooks and care plan books. for example, the rationale behind vigorous scrubbing during handwashing is that friction helps to remove dirt and bacteria.
so, you have a lot of preliminary work to do. you may have some problems with hypertension as this is considered to be more of a medical condition rather than a diagnosis, but there are symptoms, complications and tests that are done for it.
that should give you enough information to get you going in the right direction.