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- by tidwella980 Sep 27, '12We are just now being introduced to nursing diagnosis and got our first care plan assignment that's due Monday. When reading the case study, I just see a whole bunch of symptoms and I'm having a very hard time picking out the stuff for the diagnosis. I'm having a hard time picking a MAIN diagnosis for the patient, along with the r/t and aed/amb. I'm not looking for anyone to do this for me...just some pointers in the right direction would be nice. I don't even know where to begin...
Thanks so much!!
Heres the case study!
Your patient is a 70 year old male who presented at the ER with chest pain and shortness of breath. The history shows he has had a swollen leg with pain for 4 days prior to coming to the ER. He is admitted to your unit. He has significant swelling and mottled erythema of his left leg pain 5/10 while his chest pain is 10/10. The electrocardiogram shows he has atrial fibrillation. The diagnostic work shows that he has a large thrombosis in the left popliteal vein and evidence of a pulmonary embolism. The doctor has ordered he be started on IV anticoagulation therapy, best rest and O2 therapy. Physical assessment reveals diminished breath sounds in the bases. BP 130/80, P 106 and irregular, R 22, T 99 F.
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- ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.
What is your assessment? What are the vital signs? What is your assessment. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.
The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.
Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.
Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.
Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition
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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.
Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE
- 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)
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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.
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:chest pain) is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis. If we choose the complaint of chest pain. Fro example........Why does the patient have chest pain? The patient has chest pain R/T Ineffective Tissue Perfusion. From Gulanick: Nursing Care Plans, 7th Edition
definition: Ineffective Tissue Perfusion: Peripheral, Cardiopulmonary, Cerebral
NANDA-I Definition: Decrease in oxygen resulting in failure to nourish the tissues at the capillary level. Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient, or it can be more acute or protracted with potentially devastating effects on the patient. Diminished tissue perfusion, which is chronic in nature, invariably results in tissue or organ damage or death. Management is directed at removing vasoconstricting factors, improving peripheral blood flow, and reducing metabolic demands on the body.
In practice, patients often present with a combination of causative factors.
Prolonged capillary refill
Abnormal arterial blood gases
abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness
Common Related Factors
Impaired transport of oxygen
Interruption in blood flow
Mismatch of ventilation with blood flow
Decreased hemoglobin concentration in blood
Altered affinity of hemoglobin for oxygen
I've just listed above all the NANDA information on the diagnosis of Ineffective Tissue Perfusion. from the taxonomy. Only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.
Care plan reality: Nursing diagnoses, nursing interventions and goals are all based upon the patients symptoms, or defining characteristics. They are all linked together with each other to form a nice related circle of cause and effect. You really shouldn't focus too much time on the nursing diagnoses. Most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. The nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.
Some resources.....for you........
nursing diagnosis by VickyRN..http://allnurses.com/nursing-student...es-655625.html
Some example of care plans.....
- Your patient is a 70 year old male who presented at the ER with chest pain and shortness of breath. The history shows he has had a swollen leg with pain for 4 days prior to coming to the ER. He is admitted to your unit. He has significant swelling and mottled erythema of his left leg pain 5/10 while his chest pain is 10/10. The electrocardiogram shows he has atrial fibrillation. The diagnostic work shows that he has alarge thrombosis in the left popliteal vein and evidence of a pulmonary embolism. The doctor has ordered he be started on IV anti-coagulation therapy, best rest and O2 therapy. Physical assessment reveals diminished breath sounds in the bases. BP 130/80, P 106 and irregular, R 22, T 99 F.
Too bad they don't give an O2 sat as that it vital information you would normally have on this patient.
Grrrrrrr I hate it when you have to do care plans on fake patients for a care plan is ALL about assessment OF THE PATIENT......What the patient needs. What your assessment reveals.
Now look at what you know from the paragraph......
chest pain and shortness of breath,chest pain is 10/10.
swollenleg with painleft leg pain 5/10
swelling and mottled erythema
he has atrial fibrillation
large thrombosis in the left popliteal vein
evidence of a pulmonary embolism
diminished breath sounds in the bases
P 130/80, P 106 and irregular, R 22, T 99 F.
Where to start.....Your patient has a blood clot/thrombosis in the left leg. What is a thrombus? How do the develop? What contributing factors does you patient have that makes him more pre-disposed to the development of a thrombus? Does his A fib factor into the patient problem? What is Afib? What causes it? what can be complications of this arrhythmia? What is a pulmonary embolism? How do they develop? What contributing factors does you patient have? What are the treatments for these problems? What is anti-coagulation therapy what are the risks to the patient being on anti-coagulation therapy?
What I would suggest you do is to work the nursing process.......
#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.
#2. 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.
#3. 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 the next step of the process which is
#4. Determining your patients problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.
#5. How are all your interventions changing/helping this patient.
Here are some references you can look at.
- I found this......
How to Write a Case Study Paper The Nursing 52 case study paper is a complex paper involving many sections. For a full explanation of how to write a case study paper, please talk to your instructor. The information below is a basic guideline for how to write a case study paper; if there are any differences between what your instructor has told you and this website, please do as your instructor has asked.
In order to write a case study paper, you must carefully address a number of sections in a specific order with specific information contained in each. The guideline below outlines each of those sections.
Introduction (patient and problem)
- Explain who the patient is (Age, gender, etc.)
- Explain what the problem is (What was he/she diagnosed with, or what happened?)
- Introduce your main argument (What should you as a nurse focus on or do?)
- Explain the disease (What are the symptoms? What causes it?)
- Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
- Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)
Nursing Physical Assessment
- List all the patientís health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
- Explain what treatments the patient is receiving because of his/her disease
Nursing Care PlanNursing Diagnosis & Patient Goal
- Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
- Explain what your goal is for helping the patient recover (What do you want to change for the patient?)
- Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
- Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)
- Explain what the patient or nurse should do in the future to continue recovery/improvement
Your paper will be graded on how well you complete each of the above sections. You will also be graded on your use of APA style (see the APA section of this website) and on your application of nursing journals into the treatments and interventions. For integrating nursing journals, remember the following:
- Make sure to integrate citations into all of your paper
- Support all claims of what the disease is, why it occurs and how to treat it with references to the literature on this disease
- Always use citations for information that you learned from a book or article; if you do not cite it, you are telling your reader that YOU discovered that information (how to treat the disease, etc.)
- See where this is going?
You prioritize this information by what is most important to the patient first.....remember Maslows. What is the most dangerous, painful, or will kill them first. right? You may find this helpful.....Nursing Proccess & Critical Thinking Guide | NursingProccessSteps.com
maslow's hierarchy of needs - enotes.com virginia henderson's need theory. at risk is never the top priority unless this is hypothetical and there is not a real patient.
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.
- maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.
b and d needs
deficiency or deprivation needs
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
- 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.
application in nursing
- 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.
Maslow's Hierarchy of NeedsBasic Human Needs
Food, shelter, water, sleep, oxygen Safety:
Security, stability, order, physical safety
Food, water, oxygen, elimination, clothing and shelter for body, warmth and protection, activity, or sensory and motor stimulation, including sex, physical exercise, and rest
Love and Belonging:
Affection, identification, companionship Esteem and Recognition:
Self-esteem, self-respect, prestige, success, esteem of others
Love, including approval and esteem, importance, including recognition and respect, adequacy, including self-sufficiency and the need to be needed and wanted, productivity, including work an creative pursuits
Self-fulfillment, achieving one's capabilities Aesthetic:
Beauty, harmony, spiritualSocial Needs:
Identification or belonging, education or learning, religion or spiritual, recreation or play
Fundamentals of Nursing, 2nd Edition
prioritization is done by the patient's most important needs. keep in mind that the care plan is a problem solving process, so each nursing diagnosis is actually a patient problem. you list the problems in the order of which is most important of needing attention first. most instructors suggest prioritizing by maslow's hierarchy of needs. the hierarchy from most important to least important is as follows:
- physiological needs (in the following order)
- the need for oxygen and to breathe
- the need for food and water
- the need to eliminate and dispose of bodily wastes
- the need to control body temperature
- the need to move
- the need for rest
- the need for comfort
- safety and security needs (in the following order)
- safety from physiological threat
- safety from psychological threat
- lack of danger
- love and belonging needs
- self-esteem needs
- sense of self-worth
- recognition and realization of potential
nursing resources - care plans
critical thinking flow sheet for nursing students
student clinical report sheet for one patient
Now what do you think?
- Sep 28, '12 by modgoth1Absolutely wonderful advice for the OP Esme! I loved this, "Think of the care plan as a recipe to caring for your patient."