CAREPLANS HELP PLEASE! (with the R\T and AEB) - page 15

by RNinJune2007 299,122 Views | 176 Comments

Hello! I did very well my first unit, taught by a certain teacher. This unit is taught by another and the majority of my class is COMPLETELY lost! When the teacher gives examples, it makes sense but when we're left on our own,... Read More


  1. 0
    I need some help!!

    I had a complex patient that I am attempting to do a brief care plan on. My instructor wants 2 nursing diagnoses. My patient presented with Acute MI, with a hx of previous MI and severe LV dysfunction. My pt. developed HIT while in the hospital and also has CRF requiring HD 3x/week.

    I chose my first nursing dx as:

    Decreased Cardiac output r/t altered heart rate and rhythm as evidenced by dyspnea with exertion, + 2 pitting edema in bilateral lower extremities, and crackles in the bases of the lungs bilaterally.

    I cannot decide which to proceed with when doing my next nursing dx. According to Maslow the first physiological need is O2- which would include circulation and obviously my patients HIT status has put her at risk for injury. Yet elimination is right up there at the top of the list and my patient has CRF. I would assume that the real issues would take priority over the issues of which my patient is at risk right?

    Oh my, I have been out of LPN school for over 10 years and I feel over my head!!

    If I were to go with Renal Failure do you all feel that the nursing dx:

    Impaired urinary elimination r/t effects of disease, need for dialysis aeb azotemia et anuria.
    would work?

    Thanks so much in advance.
    Last edit by lpn2rnstudent on Sep 18, '07
  2. 0
    lpn2rnstudent. . .any nursing diagnosis you use is always based upon the symptoms (abnormal assessment data, defining characteristics) your patient has, not necessarily upon their medical diagnoses. renal failure is not a nursing diagnosis, but the symptoms of it can be used to help you determine a nursing diagnosis, the most common being fluid volume excess. you need to go to a textbook and read up on crf. these patients have many long-term problems that include anemia, peripheral neuropathies, platelet dysfunctions (patient already has hit as well!), pulmonary edema, and electrolyte imbalances. they usually require special diets and fluid restrictions. look at the medications this patient is receiving as well to get an idea of some of the problems the physician is already addressing that he hasn't formally listed in his h&p. nutrition and fluid are big nursing problems in renal patients, so is tissue perfusion to the kidneys (which is why they are in renal failure in the first place). they are at risk for infection and injury. this patient is at risk for hemorrhage.

    you need to go through your assessment of this patient again and list out the things you found that were abnormal. those are the defining characteristics that will determine which nursing diagnoses you use. and, you are correct. actual problems always take precedence over anticipated ("risk for") problems.

    you might also want to look at some of the posts on the "desperately need help with careplans" thread in the nursing student assistance forum (http://allnurses.com/forums/f205/des...ns-170689.html). i can't give you much more help without your having listed any specific symptoms (abnormal assessment data, defining characteristic) this patient has.
  3. 0
    Yes a good careplan book would help but as you get out into the work force all facilities have different ways they want you to write them. For school, I'm assuming it is stll the same old stuff. So you have a list of potential diagnosis Altered nutrition, Impaired Mobility, Alteration in fluid balance....pick one that states the person's problem. Then ask WHAT is causing this problem the R/T poor po intake, use of one leg, intractible vomiting. Then AEB (how know it) decline from baseline weight, unsteady gait, or decreased urine output greater than po intake.

    Basically it it WHAT the problem is in general
    then related to WHAT is causing the problem
    then AEB HOW you know.
    Go to your local hospital and see if they have any preprinted careplan cards or see how they develope them online. Good luck to you
  4. 0
    nursing diagnosis is based upon the assessment of the patient that you do. this is part of the nursing process. the process of a nurse determining a nursing diagnosis is no different than the process a doctor uses to determine a medical diagnosis or that a plumber uses to figure out why your plumbing isn't working correctly. what is different is that each nursing diagnosis has a set of criteria that the patient must have in order for a nurse to say "this patient has xxx nursing diagnosis". each medical diagnosis has a defined set of criteria that the patient must meet before the doctor can put that medical diagnosis on the patient. the criteria for most nursing diagnoses has been defined by nanda, the north american nursing diagnosis association. some nursing schools have come up with their own nursing diagnoses and the criteria that define them; they instruct their students to use them instead of the nanda diagnoses. there is no guesswork here. there is a specific process (the nursing process) involved in choosing nursing diagnoses for your patients and using them to plan the patient's goals and care. this concept is written about in the first pages of every single care plan book on the market. please take time to read those few pages to understand how the nursing process is put into action to diagnose.

    please note this definition of the words diagnosis and criteria:
    diagnosis: the resulting decision or opinion after the process of examination or investigation of the facts

    criteria: standards, rules or tests by which a judgment of something is made
  5. 0
    I totally recommend this book called "Nursing Diagnosis Handbook" by Judith M. Wilkinson. It is fabulous!!! It has a complete NANDA approved nursing diagnosis list. You can look them in the index to find the page. Under each diagnosis it gives you the 1. Defining characteristics, 2. Related factors, 3. Suggestions for use, 4. Suggested Alternative Diagnoses, 5. NOC outcomes, 6. Goals/evaluation criteria, 7. NIC interventions, and 8. Nursing Activities.

    You can also look up the possible diagnosis' by condition such as "dying patient" or "chest trauma."

    I love this book soooooo much! I'm a begginnning nursing student, so this book is like a bible to me
  6. 0
    :angryfire
    Last edit by luckynurse17 on Oct 2, '07
  7. 0
    Quote from uncled
    Here in Texas we no longer do careplans, but now were are doing concept care mapping, I think it is the same thing.
    Actually, in Central Texas, at least, we still have care plans :spin:
  8. 0
    Quote from shannon88
    I totally recommend this book called "Nursing Diagnosis Handbook" by Judith M. Wilkinson. It is fabulous!!! It has a complete NANDA approved nursing diagnosis list. You can look them in the index to find the page. Under each diagnosis it gives you the 1. Defining characteristics, 2. Related factors, 3. Suggestions for use, 4. Suggested Alternative Diagnoses, 5. NOC outcomes, 6. Goals/evaluation criteria, 7. NIC interventions, and 8. Nursing Activities.

    You can also look up the possible diagnosis' by condition such as "dying patient" or "chest trauma."

    I love this book soooooo much! I'm a begginnning nursing student, so this book is like a bible to me
    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.
    Will look around. I'm a beginning nursing student also and I have yet to find a decent book on this subject. For example, our latest case study was a trauma injury, broken femur w very large wound. The closest NANDA in all the books I've seen is impaired or altered tissue integrity but they all focus on NOCs and interventions for pressure ulcers, not trauma wounds. They just don't fit the problem very well. I know, pressure ulcers have some things in common with trauma but there are substantial differences which none of the books seem to deal with. Seems like all of the books I've seen never quite manage to list classifications which directly apply to the problems we're studying. We use the Nursing Diagnosis Handbook by Ackley, currently in print and recently but the outcomes and interventions never seem to apply to cases we encounter. Surely someone should be able to publish a coherent book on this subject.

    Thanks for any feedback.
    Last edit by aviator411 on Oct 7, '07
  9. 1
    Quote from 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.
    will look around. i'm a beginning nursing student also and i have yet to find a decent book on this subject. for example, our latest case study was a trauma injury, broken femur w very large wound. the closest nanda in all the books i've seen is impaired or altered tissue integrity but they all focus on nocs and interventions for pressure ulcers, not trauma wounds. they just don't fit the problem very well. i know, pressure ulcers have some things in common with trauma but there are substantial differences which none of the books seem to deal with. seems like all of the books i've seen never quite manage to list classifications which directly apply to the problems we're studying. we use the nursing diagnosis handbook by ackley, currently in print and recently but the outcomes and interventions never seem to apply to cases we encounter. surely someone should be able to publish a coherent book on this subject.

    thanks for any feedback.
    perhaps you are not understanding how nursing diagnoses are supposed to be utilized. they are only a tool for expressing the patient's problems. you determine what your patient's problems are from you assessment, not based, in particular, upon their medical diagnoses. just about every care plan/nursing diagnosis book author got permission from nanda to reprint the definition, related factors and defining characteristics that go with each nursing diagnosis. this is the meat of the nursing diagnosis taxonomy. any nocs and necs that are thrown in are a bonus feature provided by the authors and they pay a royalty to the owners of these two taxonomies to reprint them. the current 188 nanda diagnoses, their definitions, related factors and defining characteristics (the bare bones taxonomy) can be purchased from nanda (http://www.nanda.org/) in this publication, nanda-i nursing diagnoses: definitions & classification 2007-2008, which is the size of a pocketbook for that paltry sum of $24.95. you need to use care plan/nursing diagnosis books as references only to verify that you have classified your nursing diagnoses correctly by comparing your patient's symptoms (defining characteristics) to the ones listed under each nursing diagnosis you have chosen. if your patient doesn't have the symptoms that are listed under a particular nursing diagnosis that you think you should be using for them, then you either need to go back and re-assess your patient to find some of these symptoms, or you can't use it. a doctor can't diagnose you with cancer if you don't have the symptoms. a car mechanic can't tell you that your brake pads need replacing if he has examined them and determined that they are 90% gone. you'd be livid and question the integrity of these guys. well, you need to hold yourself up to the same standards when putting a nursing diagnosis on a patient.

    your example of a traumatic injury: broken femur with very large wound is a good example. what the does the way a wound occurred (trauma) have to do with the problem of caring for the wound? the trauma itself may have resulted in some psychological problems, but a wound is a wound. you are still left with the problem of taking care of the wound--that simple. that's what a nursing care plan addresses--nursing problems. you assess a wound and from your assessment of the wound you get your nursing diagnosis, probably impaired skin integrity because the definition of this nursing diagnosis is "altered epidermis and/or dermis" and one of the defining characteristics for this nursing diagnosis is "disruption of skin surface" (page 199, nanda-i nursing diagnoses: definitions & classification 2007-2008). the fact that it was caused by trauma is not really pertinent to the nursing diagnosis other than you might want to include it as part of the related factor. so, your nursing diagnostic statement for this would be impaired skin integrity r/t disruption of the skin surface [you could add here secondary to "traumatic injury" if you must and your instructor approves doing this] aeb [the assessment information of the wound] or impaired skin integrity r/t traumatic disruption of the skin surface aeb [the assessment information of the wound]. if your care plan book does not have specific information about the healing of a wound that you are looking for then you need to go to other resources to find this information such as your nursing textbooks, a book of pathophysiology or check for an article on emedicine. i have a pathophysiology book (pathophysiology: the biologic basis for disease in adults and children, third edition, by kathryn l. mccance and sue e. heuther) that has information in chapter 2 (altered cellular and tissue biology) that explains how cells heal and repair themselves. that's the kind of information you need to know so you know how the body is going to heal itself and to help you formulate the time elements in your goals. a question about this might show up on a nursing test, you never know. your fundamentals of nursing book or the surgical section of your nursing textbook should also have information on how wounds heal and wound care.

    i wouldn't put a lot of reliance on all the interventions and goals (outcomes) listed in care plan books. first of all, they are trying to appease a large audience. secondly, the authors are biased by what they have been exposed to in their own practice and experience. third, the actual lists of nics and nocs are much more extensive than any nursing care plan/nursing diagnosis book could ever list. so, the authors of care plan and nursing diagnosis books only pick and choose ones they want to reprint. all the nic and noc information comes from nursing research that was done at the university of iowa and is owned by them. you can actually buy the books that contain the complete listings of nics and nocs if you want.
    • this is the title of the outcomes book: nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson and meridean maas.
    • the interventions book is: nursing interventions classification (nic), by joanne mccloskey mccloskey dochterman, gloria m. bulechek, gloria m. bulechek.
    both books run about $50 each. however, you can find the same information by researching it in any good nursing textbook(s).

    a care plan is the written documentation of the problem solving process. that's all it is. nursing has defined 5 steps that we are to follow in determining these problems and going about solving them. using a nursing diagnosis only involves step #2 and provides us with a label to put on the patient's problem. the goals (outcomes) and interventions are grounded in the nursing theory we learn from our nursing textbooks. each care plan is unique to the patient's circumstances. this is why you do a thorough assessment of the patient starting at step #1 of the process. now, i understand that you are looking for resources to help you out with this, but almost all the information you need for goals and interventions are actually in the books you already have. you just need to find it and dig it out. getting to all this information is part of learning critical thinking which you need to have to demonstrate when you take nursing tests, the nclex and on the job as an rn.
    aviator411 likes this.
  10. 0
    Dayonite,

    I always enjoy and learn from your generous contributions here and this is no exception. How may I thank you for the superb lecture you have provided here?

    We (it's a group project) ended up with this for a nursing diagnosis statement: NANDA: Altered Tissue Integrity r/t injury of left thigh AEB infected wound with large qty serosanguinous drainage and yellow film-like substance covering lower wound.

    I think it's not so much a matter of misunderstanding the intent of the process as much as feeling a need for a more systematic method of routing out all the possible and most appropriate outcomes and interventions. Sometimes it seems a bit random at this point; hoping that the references we consult aren't missing something important. We want to be as thorough as possible and often don't feel we know where to look for everything we need. The cases given to us often include some ambiguity with regard to our roles and access to the patient and with regard to what outcomes we can reasonably expect and how soon we can expect them. Sometimes this information is less easy to come by.

    I still have McCance & Heuther from patho; it is a great book. I won't be selling it any time soon.

    We are gradually feeling more comfortable with all of this and your kind remarks have definitely contributed to this progress.

    Thanks again for taking the time to share your hard-earned knowledge and experience with those of us who aspire to becoming the best nurses we can be!


Top