i recommend that students follow the steps of the nursing process. the book nursing care planning made incredibly easy
is set up and organized exactly that way. the first section of nursing diagnosis handbook: a guide to planning care
by betty j. ackley and gail b. ladwig explains that care plans are developed that way as well. it really makes a lot of sense.
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- 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 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.
- 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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this 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:
- planning (write measurable goals/outcomes and nursing interventions)
- goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
- improve the problem or remedy/cure it
- stabilize it
- support its deterioration
- how to write goal statements: http://allnurses.com/forums/2509305-post158.html
- interventions are of four types
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
- care/perform/provide/assist (performing actual patient care)
- teach/educate/instruct/supervise (educating patient or caregiver)
- manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
you can also see how this has been put into action on posts on this thread:
what i can see from your posts is that you are struggling with the pathophysiology of what is going on with this patient. this patient had an mi. learning about what an mi is, what the pathophysiology of an mi is and how a pleural effusion fits into the picture along with other medical problems this patient might have will help explain many of the symptoms this patient is exhibiting. mi's, generally, are the result of atherosclerosis of the heart vessels. decreased cardiac output
is a nursing diagnosis that covers all the components of cardiac output, both the electrical component and the physical ones which includes the arrhythmias and blood volume. when the terms preload and afterload come up people start tuning off because they sound like foreign terms. htn belongs in there too, but the understanding of it is often a real puzzle for most, so they end up just turning their backs to it.
part of doing a care plan as a student involves looking up information about the medical disease the patient has, learning about it and how the doctors treat it. we need to know that information because we are often the ones who end up managing the administration of those treatments so we need to know and understand why they are being given and what the treatment is expected to do. and, in the same way, we are going to plan a few interventions of our own for many of those same things. for example--edema. it is a symptom of different types of heart failure. with an mi it is not uncommon for the heart to be weakened and some heart failure to occur. heart failure occurs in stages and over a period of time. docs watch the manifestations of it and their severity to evaluate the degree of failure. the edema is treated by the docs with things like diuretics. that is within their scope of practice. we give the diuretics. it a collaborative intervention. what we can do independently are things like keep their legs elevated to promote fluid to get back into the general circulation or encourage activity. the reason it works has to do with overriding the hydrostatic pressure (its a principle of physiology and biology).
throughout nursing school you will be asked to draw upon this kind of information to support why you are ordering certain nursing interventions. medical students are asked to do the same. if there are things you do not know, recall or understand, then you hit the books looking for the answers. that is what care plans are designed to do for students and how you will learn much of nursing, especially when you get a patient you must write a care plan on who has a disease before you have had lectures about it.