nursing care plans are problem solving. we use the nursing process which is a problem solving tool to do this. the nursing process has five steps. you begin by starting with step #1 which is assessment. you have been given a good deal of the assessment information already.
- 80 year old man
- lives alone
- wants to be independent
- doesn't cook
- eats cold cereal and hot dogs
- has the flu (influenza) - this is a medical condition and has signs and symptoms of its own
- cough (may be dry cough)
- short of breath
- rapid breathing
- diminished breath sounds
- red, watery eyes
- clear nasal discharge
- reddened nose
- cervical lymph nodes may be enlarged
- feels very tired
- states that he has been losing weight lately (you do not have empirical data, a weight to confirm this)
- daughter states he fell going to the bathroom at home yesterday
nursing diagnoses are labels (names) that nanda has made for related groupings of symptoms of nursing problems. the purpose of assessing patients is to determine what kind of abnormal data is present. that abnormal data becomes symptoms of problems which we attach names, or labels, to. those labels, if you happen to be a nurse, are called nursing diagnoses. to us nurses, many of those symptoms listed above mean something and are symptoms, or defining characteristics, of nursing problems. which nursing diagnoses? well that is a good question. it takes using a nursing diagnosis reference to determine that. nanda has a definition and list of defining characteristics (symptoms) for each of the current 188 nursing diagnoses [this is called the taxonomy]. here is where you can find some of this taxonomy 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.
- the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
step #2 is to determine your patient's nursing diagnoses (nursing problems) from the abnormal data of your assessment information found in step #1. these are what i would diagnose this patient with. information about each of these diagnoses can be found on this website: http://www1.us.elsevierhealth.com/ev...e/constructor/
except for risk for imbalanced nutrition: less than body requirements
which you must put together from the imbalanced nutrition: less than body requirements
a "risk for" diagnosis is a problem that does not exist yet. that means that you are going to perform nursing interventions to prevent
the problem from happening. to get information on how to write interventions for these types of nursing diagnoses, see post #7 on this thread: http://allnurses.com/general-nursing...ns-286986.html
- ineffective breathing pattern
- ineffective airway clearance
- ineffective health maintenance
- risk for imbalanced nutrition: less than body requirements
- risk for infection
- risk for falls
in step #3 on the nursing process you write the goals and nursing interventions for every one of the defining characteristics (symptoms) that supports each of the nursing diagnoses. just as doctors treat individual symptoms that contribute to producing a disease, we nurses do the same with each nursing diagnosis. for example, when a patient has a cold whose symptoms are a runny nose and headache people take an over the counter medication like afrin or dristan for the runny nose and aspirin or tylenol for the headache. they treat the symptoms, not the cold. you will aim your nursing interventions at the shortness of breath and rapid breathing (for the ineffective breathing pattern
), at the cough, shortness of breath and diminished breath sounds (for the ineffective airway clearance
), at the fever (for the hyperthermia
, and so one for each of the other diagnoses.
and that is how a care plan is written without having to use a care plan book.