Careplan problems

Curious1alwys, BSN, RN · Nov 26, 2006

Well, you are saying your pt has dry skin, which is one thing, but if there is no skin breakdown (a miracle considering everything you are saying is going on) then you don't have an AMB. Maybe she was thinking there had to be skin breakdown???? I would clarify that with her...

I don't think dry skin in and of itself can be a AMB for impaired skin integrity...

I think it would be r/t impaired mobility, urinary incontinence, and fragile dry skin

P_RN, ADN, RN · Nov 26, 2006

Dry skin could be dehydration.....and if the urine is very concentrated it could be irritating, and if the patient has poor mobility she may not wantor even be afraid to get up to the BR so she restricts her intake so then her urine is concentrated and her skin is dry. ......Hmmmm

And I always use "potential for" is that passe' now?

Glimmer · Nov 26, 2006

The problem is that this is not a real pt... just a scenerio. The "pt" has chronic relapsing MS. I just could not figure out what would make this a 3 part diagnosis. In class she clearly told us several times that at risk diagnosis will not have an AEB because they should not have the s/s of the condition they are at risk for. If you do then they are no longer at risk. I talked with one of the second year students and was told that I could possibly just list the assessment data that lead me to the diagnosis... which means it would read: At risk for impaired skin integrity RT urinary incontinence and impaired mobility AEB dry skin, pt unaware of urinary incontinence, muscle weakness, and difficulty ambulating. It just really does not sound right to me worded that way. I am going to email my instructor again and maybe she will email me back this time.

Thanks again!

Alnee

AggieNurse99, BSN, RN · Nov 26, 2006

I had the same thing happen to me on one of my careplans this semester (1st). I caught up to my instructor when she was in an office with a few other instructors from our level, and stated "Per Ms. So-and-So's lecture on the nursing process, a 'risk for' diagnosis does not have AEB" and Ms. So-and-So spoke up and said "Yes, that's what I taught them" and another instructor said "She was just tired" and my clinical instructor laughed and it was ok. (Yes, nursing professors are only human).

Glimmer · Nov 26, 2006

I have emailed my instructor again to see if she can offer me more assistance. As of right now I am going to print out two different careplans... one with the AEB and the other without it... and then if nothing else I will ask her in person. At least she wont be able to say I was not prepared nor that I did not make an effort to try to understand what I was doing.

Thanks

Daytonite, BSN, RN · Nov 26, 2006

Well, the first thing that went through my mind on this was that it was a case scenario and that your instructor probably had a definite answer in mind and an anticipatory diagnosis (one starting with the words "Risk for") wasn't one of the answers.

You are correct though. When you have an At Risk diagnosis, as you have worded it, you do not have any AEB items. The reason is because AEB items are actual assessment signs and symptoms that you have made during your data collection. Well, this is a problem that does not even exist so has no actual signs and symptoms yet.

In sequencing nursing diagnoses, anticipated problems go to the bottom of the list. So, my question to you is, what other diagnoses did you have for this patient? You can care plan for potential skin breakdown in the nursing diagnosis for Incontinence and that settles the problem in my mind:

Urinary Retention R/T inhibition of reflex arc AEB overflow incontinence and inability to know when there is need to urinate.

You merely include nursing interventions to keep the skin dry, clean and protected from breakdown.

As for the dry skin, do you see this as a problem? I don't. More importantly, however, does your instructor? If so, do a little research on dry skin and it's treatment. However, I can't think of any nursing diagnosis at the moment that you could pair this with. Sometimes there are just some minor patient problems that there are no nursing diagnoses to cover. I would say that it's OK to ignore the dry skin, but would your instructor? I would probably opt for Self-care deficit: bathing/hygiene R/T weakness AEB inability to self-apply emollients to dry skin. The FUN (?) of writing care plans is that there is sometimes more than one way to skin a cat.

And I always use "potential for" is that passe' now?

Yes.

Glimmer · Nov 27, 2006

Thanks everyone!

I got an email back from my instructor... I was right in my thinking (as you guys have told me here) that I could not have the AEB with a potential problem. The problem she has with my diagnosis is that I incorporate 3 into one... the urinary incontinence, impaired mobility, and skin intergrity. That makes sense to me now that I go back and read it.

Once I get my diagnosis I am fine from there... It is just getting started that makes this hard. Hopefully that will become easier with time!!! Thanks to everyone for the help!!!!!!!

Alnee

Daytonite, BSN, RN · Nov 27, 2006

Glimmer. . .as someone who has written a lot of care plans, I specifically did a lot of study over this past summer of NANDA and had my head buried in a number of care plan books. My goal was to be able to help you students with your care plan writing when you were asking questions here on the forums.

If there is one thing that was very clear to me about the care plan process it is how one arrives at choosing nursing diagnoses. I struggled with this when I was a student some years ago myself. But, I can tell you with a great deal of confidence now that it all starts with the data that you collect on your patients. It doesn't necessarily have to be what you got from your own assessment. It can be data from what the doctor had to say or lab and x-rays. Anything that you cannot say is "normal" can be tagged as a patient problem that nursing can, hopefully, address and do something to help the patient with. When I was in nursing school 30 years ago, we just listed these problems one-by-one and put nursing interventions with them on our care plans. Today, NANDA wants us to group the problems and put labels on them called nursing diagnoses and then put nursing interventions with them. It took me 20 years and a lot of reading this summer to realize that very simple distinction between my training 30 years ago and what you are being taught today.

NANDA has actually given nurses guidelines in how to choose nursing diagnoses. The one care plan book that I am familiar with that lists these guidelines is the one by Ackley and Ladwig. They went one step further and created an alphabetized index to help care plan writers cross reference symptoms with possible nursing diagnoses. Otherwise, you have to memorize all the stuff. I also obtained a copy of Nursing Diagnoses: Definitions & Classification 2005-2006 published by NANDA International which has that information, but without the nursing interventions and outcomes printed in it.

The only way I can see to make this process easier to for you is for you to put each abnormal assessment item from a patient on an index card and start sorting these cards into piles that will eventually become a nursing diagnosis. You would have to do this for each patient. Students that are being taught care maps are doing care planning this way.

One of the biggest problems I am seeing as I respond to students asking for help with care plans is that they have missed important data. Often they didn't review the chart completely. But, even more complex is that they did observe something in their patient, but didn't realize that it was an abnormal symptom, so it didn't get written down in their notes. This is just due to inexperience. That is something that has to be discovered from re-reading descriptions of the pathophysiology of disease states. This is why I will often list links to information about certain disease conditions along with answers in some of my posts. I can't know what a student has missed in observing their patient since every patient is unique. I can only guess what might have been missed based on my years of experience.

The handful of care plans that you will write as a student are only an introduction to the skill. It will by no means make you a master at it. But, hang in there and put your best efforts into them. There are many things to learn from care plan writing: critical thinking, knowledge of the disease process and knowledge of nursing care.

I applaud your efforts to hone your skills. Keep at this. Practice makes perfect as we all know! :1luvu:

ef0zzy · Jan 6, 2007

yeah so our LVN class is being tested about 3 days into our program with 2 careplans already *practice of course...and all of it is just written examples the teacher made up, but for the sake of early exposure*...

the thing that is bugging me is that i see a problem with a patient and when we review the MAIN priority i'm basically off by a long shot.

like the most recent one we did the patient had symptoms to that of nausea/lack of nutrition (we were doing this in groups) and like the main priority of concern was for the patient's deficiency of fluid volume..

i felt kinda dumb not finding that main priority like as if i was really assessing a pt im scared i might be treating them for something completely not necessarily needed RIGHT away....

a little frustrating right now but im telling myself that it's still early and i need to look more harder into the tell tale signs... and looking more into care plans in the book of course haha

Daytonite, BSN, RN · Jan 6, 2007

the thing that is bugging me is that i see a problem with a patient and when we review the main priority i'm basically off by a long shot.
i felt kinda dumb not finding that main priority like as if i was really assessing a pt im scared i might be treating them for something completely not necessarily needed right away....
a little frustrating right now but im telling myself that it's still early and i need to look more harder into the tell tale signs... and looking more into care plans in the book of course haha

most nursing programs give their students some sort of guidance on how to prioritize their care. with nursing care plans, many programs use maslow's hierarchy of needs as the benchmark. you can see a listing of these needs and how they are listed in priority at this website:

http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs - maslow's hierarchy of needs

if you have a copy of nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig you will find a diagram of maslow's hierarchy on page 1325 with a sorting of the various nursing diagnoses that would fit under the five major categories of needs in the pages that follow (pages 1326-1328). you still need to make priority decisions regarding the breakdown within the major categories, but that is relatively easy to do, once you know what those various needs are and the level of priority that maslow has assigned them.

his first level of needs that have to be satisfied are the physiological ones. the priority list of physiological needs goes like this (from ackley and ladwig, page 1325):

oxygen - this includes what is commonly referred to as the abcs, or airway, breathing and circulation. but, oxygen needs to go to the brain first, next to the heart, lungs and other organs is how the priority goes.
food - if a body doesn't get enough nourishment in the form of fluid, protein, carbohydrates, vitamins and minerals, it isn't going to stay alive long enough for the remaining things to be of much significance - the fluid volume and gi related nursing diagnoses are included here
elimination - what goes in must come out, both solid and liquid
temperature control
sex
movement - this refers to all the mobility nursing diagnoses
rest - sleep
comfort - this is, generally, where issues of pain and some of the adls are addressed

you will see that the ackley/ladwig listing is just a tad different from the listing in the website link i've listed above. however, your fluid requirement is right up there near the top in both references.

i would recommend that you ask your instructors how they want you to determine priorities of patient's needs to be clear on this for future assignments as your grade may depend on it. mention maslow if they don't and see what kind of response you get from them. also, you might want to review any notes or handouts you were given to see if maybe you missed this information. there are other systems used to prioritize needs (i.e., gordon's 11 functional patterns). learning the nursing process and prioritizing care is complicated and is all part of learning to think critically. it takes time and practice. but, keep working at this!