don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics
here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
- assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions 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)
so your patient is obese (imbalanced nutrition > than needs, knowlege deficit, body image) , has an infection in his le, (impaired mobility) he complains of pain(acute pain/chronic) he has lower extremity edema and abnormal renal function....whether he admits it or not(knowlege deficit. he lacks insight to his disease and disease process
care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.
assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.
a nursing diagnosis standing by itself means nothing.
the meat of this care
plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.
what i would suggest you do is to work the nursing process from step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.
care plan reality: what you are calling a nursing diagnosis (ex: activity intolerance) is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition).
ok....first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. let me try to help you. there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) http://allnurses.com/general-nursing...ns-286986.htmlyou can also use the search on this site to lead you to care plans. i have supplied links of examples at the bottom for care plans.
then think...... maslows hierachy of needs. maslow's hierarchy of needs - enotes.com virginia henderson's need theory
maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.
- self-actualization – e.g. morality, creativity, problem solving.
- esteem – e.g. confidence, self-esteem, achievement, respect.
- belongingness – e.g. love, friendship, intimacy, family.
- safety – e.g. security of environment, employment, resources, health, property.
- physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis.
b and d needs
deficiency or deprivation needs
- maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.
the first four levels are considered deficiency
or deprivation needs
(“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs
growth needs or b-needs or being needs
application in nursing
- the needs maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
- growth needs are the highest level, which is self-actualization, or the self-fulfillment.
- maslow suggested that only two percent of the people in the world achieve self actualization. e.g. abraham lincoln, thomas jefferson, albert einstein, eleanor roosevelt.
- self actualized people were reality and problem centered.
- they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
- they tended to be spontaneous and simple.
maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.
you may also like these resources...... i strongly suggest you budget for a good care plan book as you will need it...alot! i hope this helps.
nursing care plan | nursing crib
nursing care plan
nursing resources - care plans
understanding the essentials of critical care nursing
nursing care plans, care maps and nursing diagnosis
cns: problem oriented nursing care plans