I need help with understanding how do a care plan.

RescueNinjaKy · Mar 26, 2015

At all nurses, people love to help but generally we would like to know what you have so far.

To get started, understand the criteria that your instructor has set. How many nursing diagnosis does she expect?

You want to do your assessment on the patient. Your nursing diagnosis is not based on the medical diagnosis. It's based off your own assessment, which can at times relate to the medical diagnosis. After you have your assessment, look at the problems and formulate your nursing diagnosis. You should be basing it off the assessment and the nanda. Generally you want to prioritize it based on needs, as in what's the most serious or life threatening first then move on.

From there you want to proceed with planning, what you want the outcome to be for the patient. Make it realistic and measurable.

Then comes the intervention, which is what you did to get to the goal.

Then comes the evaluation, whether you met the goals or not.

You Will probably get more advice from other posters. Usually @esme and @greentea love to help students and Will post their instructions and guidance. They're super helpful so be on the lookout for it.

SierraBravo · Mar 26, 2015

A nursing care plan should not have any mention of a medical diagnosis. Nurses are not Physicians and, as such, cannot make a medical diagnosis. We can, however, make nursing diagnoses and develop a care plan to support those diagnoses.

LoriRNCM, ADN, ASN, RN · Mar 26, 2015

A medical dx? Really? OK wait, now that I recall, on a concept map in mother baby we had to list the medical dx (like C section) at the top of the page, then list our nursing dx and interventions and goals and outcomes, blah blah. If she asks for one medical dx and a few nursing dx, then just do that. And as all the members of the crusty old bat society on Allnurses have so lovingly preached to me for two years (thank God for that! :yes: ) a nursing diagnosis is NOT supposed to be BASED on the medical dx. It is based on YOUR assessment of the pt, what YOU are seeing in your pt at that time that needs intervention. So it's like the medical dx part is useless, although your instructor is asking for it. I'd stick it in the box or circle or wherever it needs to go on your concept map, then forget about it while doing your nursing diagnoses.

akulahawkRN, ADN, RN, EMT-P · Mar 26, 2015

I wouldn't say the medical diagnosis useless, it's that it's formulated in a different way than a nursing diagnosis is. Both are based off of a data set and that data set can be an identical data set. What you might want to do (for now) is look at a medical diagnosis and look at the diagnostic criteria to see what may have been used to arrive at the medical dx. You now have at least some idea what the patient looks like, so now you look at the nursing side of this from that data set you derived. It will be different from the medical diagnosis because you're looking for the body's response to the disease process and you can find that from the data set.

Now here's the real trick... once you see the patient for yourself, get your own data set (do your own assessment) and from there you'll determine the nursing diagnosis. It's very possible for patients to have several nursing diagnoses all related to a medical diagnosis, but we're looking at things differently than a medically trained person will.

The above is simply because your instructor apparently wants you to list a medical diagnosis in your nursing care plan. Perhaps your instructor wants you to be able to see the differences between the two ways of doing things and why nurses do things the way we do.

The only way to go from a medial diagnosis to nursing diagnosis or vice-versa is to completely reverse engineer "it" and see what comes out of it. Since they're very different in the approach, it's possible that a medical diagnosis yields multiple nursing diagnoses while a single nursing diagnosis may yield a very different medical diagnosis than actually happens while a constellation of NDx's paints the "right" picture for a given medical diagnosis. Neither is wrong, they're just very, very different.

buttercup99 · Mar 28, 2015

It sounds like you pick a medical Dx and then list examples of what kinds of nursing diagnoses you might expect to see in a patient.

Eg. Congestive heart failure (med dx) might have potential for fluid overload, and/or some of the breathing related nursing diagnoses.

NurseGirl525, ASN, RN · Mar 28, 2015

I get my medical dx from the chart. The medical dx comes from the physician. Then I can relate my nursing dx from the medical one based on my assessment. We usually will put the medical dx in the middle of the map. Then we usually have 3 nursing dx coming off of that. Then for each nursing dx we come up with interventions and goals.

You may say have a post OP patient who had a joint replacement. A nursing dx could be acute pain. You would then come up with interventions and goals for the a cute pain. I hope that makes sense.

nurseprnRN, BSN, RN · Mar 28, 2015

A nursing care plan should not have any mention of a medical diagnosis. Nurses are not Physicians and, as such, cannot make a medical diagnosis. We can, however, make nursing diagnoses and develop a care plan to support those diagnoses.

Sorry I've been away for a few days, and Esme has been indisposed. Here's the scoop on nursing diagnosis, medical diagnosis, and more.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis or your plumber diagnoses the cause of that drip, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor, and it is a myth that this is not allowed. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." You can thumb through your NANDA-I 2015-2017 and find lots and lots of medical diagnoses as related factors.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $39 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at students.

NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

About Risk forâ€ diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed as a priority, as safety ranks above all of the physiological needs in Maslow's hierarchy.What are nurses for if not to protect a patient's safety?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real" or "actual." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics for the current edition.

Third: This sort of assignment is often made not only to see if somebody can recite rote information but to elicit your thought processes and see how well you can defend your reasoning. There is often no single priority; defend yours. Your faculty will be gratified to see your thoughts to make your case.

So, what is the reasoning you have applied to your ranking, as applied to a specific patient or to people in general?

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Endowed · Nov 13, 2015

WOW! I will be starting Nursing School in Spring of 2016 and I decided to start reading up on 1st semester case scenarios especially on "Care Plan" and "Nursing Diagnosis". God bless you all for always throwing in more light each time a student asks a question or confused about something. Will definitely be getting the NANDA book right away. The truth is I don't think one can ever prepare enough for nursing school; not withstanding, I will get the book and read the areas the previous poster Grntea or NurseprnRN posted. Thanks to Esme too, even though his/her post isn't here, I've seen and read a lot about their posts.

Thank God for AN, best nursing site ever! (IMO).