Cardiac care plan
0Apr 22, '13 by llee316I am working on a care plan for my patient who is 78 yr old, was hit by a car and suffers from a femur fracture due to the accident. He had ORIF sugery, CHF, CAD, HTN. He had a pacemaker inserted 3 years ago(5 leads...??)after a heart attack. His heart only has 30% output. He is at TCU and is undergoing PT. He is also on a cardiac diet. I wish I had lab values but unfortunately our teacher did not inform us of most of the things we should have collected until after the clinical experience. Any help of a diagnosis would help and be appreciated greatly. I am stuck on this one.
0Apr 23, '13 by allie86Hey I just did a cardiac care plan last week and got some great feedback on here too. If you go to this link or do a goggle there may be some things to help you
1Apr 23, '13 by Esme12, BSN, RN Senior ModeratorWelcome to AN! The largest online nursing community!
What makes this care plan about the patients heart.....did you instructor say it must be? Why are you focusing on the heart when that patients "problem" is their leg?
Care plans are all about the assessment of the patient? All about what the patient needs. What semester are you? What care plan book do you uses?
Tell me about your patient. What do they need? What is their main complaint?
So you know what to look for on your next patient a critical thinking sheet was made by Daytonite...(rip) to help students
critical thinking flow sheet for nursing students
student clinical report sheet for one patient
0Apr 23, '13 by GrnTea, BSN, MSN, RNQuote from llee316Where is your nursing assessment of his condition? This is all medical diagnoses.I am working on a care plan for my patient who is 78 yr old, was hit by a car and suffers from a femur fracture due to the accident. He had ORIF sugery, CHF, CAD, HTN. He had a pacemaker inserted 3 years ago(5 leads...??)after a heart attack. His heart only has 30% output. He is at TCU and is undergoing PT. He is also on a cardiac diet. I wish I had lab values but unfortunately our teacher did not inform us of most of the things we should have collected until after the clinical experience. Any help of a diagnosis would help and be appreciated greatly. I am stuck on this one.
See, you are falling into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.
Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.
You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.
This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.
You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.
There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.
A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."
"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."
To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!
If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:
1, health promotion (teaching, immunization....)
2, nutrition (ingestion, metabolism, hydration....)
3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
5, perception and cognition (attention, orientation, cognition, communication...)
6, self-perception (hopelessness, loneliness, self-esteem, body image...)
7, role (family relationships, parenting, social interaction...)
8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
10, life principles (hope, spiritual, decisional conflict, nonadherence...)
11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
12, comfort (physical, environmental, social...)
13, growth and development (disproportionate, delayed...)
Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.