all care plans
begin by assessing the patient and gathering information about them and the medical condition they have before you even begin picking nursing diagnoses. assessment includes:
- a physical assessment of the patient
- assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
- data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians)
- knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition (in this case, an umbilical hernia) that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it. there are websites where you can find information about the surgical repair of this condition listed on this thread:
after you have completed the above, make a list of the abnormal data you find, or the abnormal responses/symptoms, this patient is having. those are necessary to the remaining work that needs to be done on the care plan (choosing the nursing diagnoses, choosing the goals/outcomes, and deciding on the nursing interventions to use).
if you will list the abnormal data, i will help show you and explain to you how to choose nursing diagnoses. or, you can read about it on this thread: