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grtea always gives great advice. so, your professor wants you to use this diagnosis. in the future........let the patient drive your diagnosis, 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? 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?
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.
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.
daytonite...........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
. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help
you in writing care plans
so you diagnose your patients correctly.
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)
a dear an contributor daytonite always had the best advice.......check out this link.
so your patient with downs is immobile and would need to have meticulous skin care to prevent breakdown right? active/passive rom to prevent further contractures, right? what would you like to see for this patient in the future? minimal/no skin issues and no contractures, right? does the patients incontinence impose a risk?
care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and try to fit the patient into diagnosis. some other helpful links.
nursing care plan | nursing crib
nursing care plan
nursing resources - care plans
nursing care plans, care maps and nursing diagnosis
understanding the essentials of critical care nursing