Looking for some guidence on a care plan.
- 0Oct 18, '11 by Miranda DeVoreHello I am working on my first care plan and am trying to come up with the risk factors associated with an ostomy bag. my nursing diagnosis is Impaired Skin Integrity R/T irritation due to moisture AEB bowl secretions. The only thing that i can think of is at risk for falls. Im not trying to get others to do my work just need a little guidance because my teachers are not of much help.
Thanks sooo much for any help
- 0Oct 18, '11 by Esme12, BSN, RN Senior Moderatorthere are many resources on this site for help. here is one from rnwriter and daytonite (rip) that have helped many!
let me tell you what may not have been explained very well. a care plan is merely the written documentation of the nursing process. the nursing process is nothing more than a problem solving method. you and i have used this same problem solving method every day of our lives even before going to nursing school. the profession of nursing has just given it a name and some rules for us to follow in getting to the final solution(s).
- assessment (collect data from medical record and by doing a physical assessment of the patient)
- nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
here are a couple of care plan sites for free ideas
- 1Oct 18, '11 by Cloverytry thinking of some psychosocial diagnoses...
risk for disturbed self-concept or body image
risk for ineffective sexuality patterns or sexual dysfunction
risk for loneliness (r/t decr. socialization & anxiety about leaking fluids & possible odor)
does your patient know how to care for it? there could be a risk for ineffective self-help management or a knowledge deficit.
You should pick up a careplan book that has possible nursing diagnoses listed for medical conditions - it really helps!
- 1Oct 18, '11 by xtxrnQuote from Miranda DeVoreOnce you get the hang of using your own words, you'll wish you had a photo of whoever came up with NANDA on a dart board When you get away from NANDA, you can simply take the problem, and write it down. No more "potential" this, or "actual" that, or whatnot.Thank you so much for your input, it's kinda confusing for me because our program is leading us away from NANDA diagnosis and now just calling it a Problem and putting things in our own words. I think using the NANDA Diagnosis is much easier.
You can write:
Social isolation r/t fears about ostomy odors...and be done with that issue.
- 0Oct 19, '11 by Esme12, BSN, RN Senior ModeratorQuote from Miranda DeVoreThe way I did care plans 34 years ago....kind of like fashion, Hold on long enough and it will come back in style.Thank you so much for your input, it's kinda confusing for me because our program is leading us away from NANDA diagnosis and now just calling it a Problem and putting things in our own words. I think using the NANDA Diagnosis is much easier.