Help with Care Plans

My clinical instructor requires us to list 'as manifested by' for risk diagnoses. She said to ignore our textbooks that say 'risk for' is a two-part.

In fact, we had a major paper due recently (not part of weekly clinical care-plans) and she booted my paper right back to me to fix and make 'risk for' a three part diagnosis. I thought she was just doing this in our weekly carepans for clincal, but no. It's for major papers as well. Is this unusual?

Originally Posted by multicollinearity

My clinical instructor requires us to list 'as manifested by' for risk diagnoses. She said to ignore our textbooks that say 'risk for' is a two-part.

It doesn't follow NANDA guidelines. However, this is a school and grading situation and you are obliged to follow the rules you are given. This is really not a problem as long as the instructor applies the rules consistently in grading. I would make sure that your manifested evidence for these diagnoses clearly relates to a specific problem that you're addressing.

In my BSN program we were not allowed to use NANDA wording (language) for our nursing diagnoses. We had to construct nursing diagnoses using language that conveyed the nursing problem but did not duplicate what NANDA said. It was possible to do that using a copy of Roget's Thesaurus for reference.

2nd semester student here...I need some help...My patient last night was a 98 yr old female w/admitting diagnoses of Jaundice. She also had a small stage 2 pressure ulcer-sacral. Her past history included multiple falls, Hypertension, CHF, Renal Failure, Osteoporosis. Currently suffering from severe diarrhea, and also had an ERCP done on 4/17--"multiple stones, stent placed" The only medications listed was Flagyl, 250 mg at 16:00 and 22:00, Darvocet bid and ASA 81 mg / day
she was currently on 3 liters of O2 nasal cannula.
When I initially went to her room, I was told that she had been moved to a room closer to the nurses station as she was failing quickly. She was not responding other than opening her eyes once in awhile, when I spoke to her and was restless, but earlier in the day she I was told by the nurse that she was having pretty normal conversations with her.
Pulse was 93, respirations: 36 BP 102/82 pulse ox 73.
She was put on 15 liters O2 non rebreather mask.
she went further downhill... Resp. 42 & shallow, BP 60/36 pulse 90,and within 2 hours her care was changed to "comfort measures" --(had a DNR)--all meds d/c'd, morphine 1-2 mg q 2 hours, IV. They didn't think she would make It through the night.
I'm attempting to start a careplan to turn in to my instructor. (boy, its tough to not get emotional!) I admit to having problems prioritizing (as indicated by my last request for help!) but where do I start? Do I begin with the information I was given, and then progress to "Death anxiety?" I need 4 Nursing Diagnoses... I have several in mind, but this patient was dying. I think her pain and making her as comfortable as possible is most important, yet working up 3 assessments, 3 interventions and 3 teachings on FOUR diagnoses has me in a quandry.
I'm starting to work on this now, and will check back for some advice if someone can help. I really appreciate it!

imac. . .how to go about starting a care plan was detailed in the first few posts of this thread.

1. make a list of your patient's symptoms
   • jaundice
   • stage 2 pressure ulcer on the sacrum (What were the measurements, any drainage, appearance?)
   • history of multiple falls
   • severe diarrhea (How many a day?)
   • multiple stones and stent placed per ERCP on 4/17 (where were these stones and were they the cause of the jaundice?)
   • Flagyl, 250 mg (why was she getting Flagyl? What kind of infection was being treated?)
   • Darvocet bid (Where was the pain that this was addressing?)
   • ASA 81 mg / day
   • 15 liters O2 non rebreather mask (Did you get any lung sounds or blood gas results?)
   • Pulse was 93, respirations: 36, then went to Resp. 42 & shallow, BP 60/36 pulse 90
   • pulse ox 73
   • not responding other than opening her eyes once in awhile
   • restless
   • her care was changed to "comfort measures" - DNR
   • all meds d/c'd, morphine 1-2 mg q 2 hours, IV
2. using that list you will
   • determine your patient's 4 nursing problems (nursing diagnoses)
     • if you had more lung assessment information other diagnoses could be used - these are prioritized by Maslow
       • Impaired Gas Exchange (supporting evidence: pulse ox of 73, restlessness, pulse of 93)
       • Ineffective Breathing Pattern (supporting evidence: respiratory rate of 42 and pulse of 93)
       • Diarrhea (supporting evidence: severe diarrhea - needs more description)
       • Impaired Physical Mobility (supporting evidence: not responding other than opening her eyes once in awhile, placed on Morphine - you also need more description that she is not moving or turning on her own)
       • Impaired Skin Integrity (supporting evidence: description of the Stage II sacral ulcer)
       • Chronic Pain (supporting evidence: ?, getting an analgesic)
       • Risk for Falls (supporting evidence: history of multiple falls)
   • determine goals - based upon the results you expect from the nursing interventions you will be ordering (writing goal statements: http://allnurses.com/forums/2509305-post157.html)
   • determine nursing interventions - ordered for the supporting evidence (symptoms) associated with each nursing diagnosis

To use Death Anxiety the patient has to be making statements to you or the others on staff about concerns about her death, yet you have listed nothing about that.

To diagnose, you really need to use a nursing diagnosis reference since every nursing diagnosis has a set of defining characteristics (symptoms) and your patient must match with at least one of them. I used NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 to double-check the supporting evidence (defining characteristics) for the diagnoses I chose above.

In my opinion, the two top priority diagnoses that I would treat are where most of the nursing care would be focused: keeping the airway open and keeping the patient turned

1. Ineffective Breathing Pattern
2. Impaired Physical Mobility

The choice of what to use for priority diagnosis depends on the behavior the patient is exhibiting. You seem to indicate that she has pain, but my thinking is that her breathing is probably more of a problem which the morphine will help. Here are links to information about end of life care, but they are not nursing sites. They will give you an idea of what "comfort care" involves.

• http://www.mywhatever.com/cifwriter/.../ff_index.html
• http://www.stvincent.org/ourservices/hospice/preparing/default.htm

I really appreciate the time you've taken to reply to my request. I wish I could send you a box of chocolate!
I have a bit more information...Some of the information is missing, and even my instructor could not find it in the chart.
The pressure ulcer was about 3 cm in diameter, slight drainage...serosanguaneous Although the patient wasn't talking by the time I got there, she would grimace and moan slightly when positioned on her back, so we opted to move her from side to side..however, the nurse said she had alot of pain in her left hip, verbalized by the patient earlier in the day. Xray did not show any fracture. The darvocet was prescribed for the complaints of pain from lying on her back (?pressure ulcer?) and her
hip.
The only entry in the chart regarding he ERCP was that she had Obstructive Jaundice.
The "severe diarrhea"--that was my description. In thinking about it, it was watery stools, but 4 to 5 per day. We could not find an indication for the Flagyl.
her lung sounds were clear, but her very shallow breathing made it difficult to evaluate completely as she couldn't respond with deep breathing. Did I miss something here?
No ABG's were drawn - her respirations went down quickly, and the nurse got an order for the rebreather mask asap---before that she was on 3 liters / nasal cannula (Not sure if I mentioned that)
Her labs were: WBC 8.9 RBC 3.93 (L) Hgb 13.4, Hct 39.5, Platelet count 127 (L) Na 141, K 3.7 BUN 66 (H) CREATNINE 3.1 (H) GFR i 15 (less than 15 is kidney failure, right?) These were drawn that morning.
The staff nurse told me that when she was talking earlier in the day, she told her "I think I'm dying-I hope my family understands-I'm tired"
I have worked up impaired gas exchange and ineffective breathing pattern so far, and started on pain. I just don't know if I have enough based on her statement of death to consider it death anxiety--she was definitely anxious/restless, but I would be too if I couldn't get enough O2!
Just want to say that I think you are a saint. I've printed and spent some more time on this site, including the links you suggested. They too were helpful. Thanks again for your time.

Thank you so much for that very detailed description. I am going into my second year at a Community College and I am hoping with your help that I will be able to write authentic care plans using my own assessment findingsand not some book that a seasoned professional has written. We as students sometimes take the short cut if only we would take our time and actually get the understanding. We are so overwhelmed with work and listening to other nurses saying they don't have to do care plans, we just take a short cut instead of really understanding. It would also proably help with us during our testing. Thanks again

Can anyone help distinguish GOALS as opposed to EXPECTED OUTCOMES?

I am really struggling with my very first care plan - for a lady who has been admitted for asthma exacerbated by an URTI, and we have to focus on the nursing diagnosis of Impaired Gas Exachange.

I can detail a whole bunch of expected outcomes, because they are specific, measurable etc etc, but what then is a goal? Is it just a broader overview of all the EO's? Is it something to do with the 5 goals of respiratory care; clear the airway, mobilise secretions, reduce WOB, oxygenate system and promote compliance and self care...?

AHH!! I've been an AIN for ages now, who ever knew I'd struggle so much with this!

[quote=Smurfie;2833866]Can anyone help distinguish GOALS as opposed to EXPECTED OUTCOMES?

I can detail a whole bunch of expected outcomes, because they are specific, measurable etc etc, but what then is a goal? Is it just a broader overview of all the EO's? Is it something to do with the 5 goals of respiratory care; clear the airway, mobilise secretions, reduce WOB, oxygenate system and promote compliance and self care...?


To make it rather simple, my instructor explained the difference as:
Goals- long term (still must be measurable etc)
Expected Outcomes- short term. Hope this helps

This has been discussed before and there are lots of opinions on it. My first suggestion is that you discuss this with your instructors since they are ultimately going to be grading you. Then, here are two threads that probably have the most information you are going to find on allnurses about it:

• http://allnurses.com/forums/f205/desired-outcomes-goals-help-103342.html
• http://allnurses.com/forums/f205/help-goals-outcomes-291943.html

Has anyone heard of a diagnosis of "high risk for impaired skin integrity"?

I'm quite familiar with the "risk for" diagnoses...but what about this "high risk" label?