you must follow the steps of the nursing process when writing a care plan.
- 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/procedures that have been done to learn about the signs and symptoms 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)
it all begins with assessment. read what you need to do under the step of assessment. you have to complete that work first before working on finding nursing diagnoses and interventions. this patient had surgery. did she have a general or epidural anesthesia? she needs to be monitored for the signs and symptoms of the complications of anesthesia. she has an incision that needs attention. then, she has trauma from being in labor that needs to be assessed and monitored. what are the complications of having been in labor? how have her tissues been injured by labor? why can't you see the damage with your own two eyes? these are things that have to be looked for when doing an assessment of the patient and don't say that they are normal because they are not. when a 7 or 8 pound baby tries to get through a vagina they leave traumatic injury behind. if you don't know what these injuries are, look them up in your ob book or on these two websites:
both sites also have assessment information and information about complications of cesarean sections.
complications of general anesthesia include the following. some of these can be potential nursing problems. patients are kept in the hospital after surgery to monitor them for potential problems as a result of anesthesia and surgery:
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- surgical pain
- nausea/vomiting (paralytic ileus)
complications of epidural anesthesia include the following. some of these can be potential nursing problems. patients are kept in the hospital after surgery to monitor them for potential problems as a result of anesthesia and surgery:
- rash around the epidural injection site
- nausea and vomiting from the opiates administered
- pruritis of the face and neck caused by some epidural narcotics
- respiratory depression up to 24 hours after the epidural
- cerebrospinal fluid leakage and spinal headache from accidental dural puncture
- sensory problems in the lower extremities
now, from all the information you are compiling about your patient and any new assessment information that you may have missed before, you move on to the second step of the nursing process where you make a list of your patient's abnormal assessment data--and she will have some. i already know she has an incision which you need to describe. she may also have some kind of wound care for it. i also know she will need instruction on how to care for this wound upon discharge. this could be part of how you are going to address the problem of the wound or a knowledge deficit. will she be able to shower or bathe at home with this incision? if she is breastfeeding there is a nursing diagnosis for that whether she is having any problems with it or not
. she will have problems with mobility. wouldn't you if you had just had your pelvic area cut into and had to get up and go to the bathroom and carry a 6-8 pound bundle around in your arms (think about it)? these are all nursing problems that are based upon assessment. now, you may have faltered in assessing these things--that's ok. it's time to learn them now. that's what your ob rotation is for and what you are supposed to learn from sitting down and working on a care plan--what you missed seeing and realizing at the time were symptoms of nursing problems.
every nursing diagnosis has a set of symptoms. nanda has very obligingly created a taxonomy that lists the symptoms (nanda calls them defining characteristics) for each of the current 188 nursing diagnoses. when you are first working with nursing diagnoses you should use some sort of nursing diagnosis reference to help you in finding and classifying a patient with nursing diagnoses. there are several ways to get 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 also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
to diagnose, you are looking to match your patient's symptoms with defining characteristics of appropriate nursing diagnoses. i also recommend that you read the definitions of the nursing diagnoses because they are the true description of the problem. the short 3 or 4 word thing we all commonly call the nursing diagnosis is actually only a shorthand label.
in the same vein, your nursing interventions are based upon those same symptoms that your nursing diagnosis is based on. those symptoms are the evidence that support the problem, or nursing diagnosis. without them there would be no problem, would there? so, isn't it logical that your nursing care efforts are aimed at these symptoms? your interventions will be to
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- care/perform/provide/assist (performing actual patient care)
- teach/educate/instruct/supervise (educating patient or caregiver)
- manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
and your goals will be what you hope will result from your interventions so they have to be linked with your interventions which are linked to the symptoms. your goals will either
- improve the patient's condition
- stabilize the patient's condition
- support the deterioration of the patient's condition
bottom line. . .the foundation of the care plan is built on your assessment data. no short cuts on this.