since you have the ackley/ladwig nursing diagnosis book
, i have to ask if you have read section i of the book? it is only 14 pages and it explains what the nursing process is and how to determine a nursing diagnosis and write a nursing care plan. in particular, focus on the section titled "step 2: nursing diagnosis (ad
pie)", it's only about 3 and a half pages long.
i can't help but think that something is not being understood correctly when i read on some of the student posts that they are not allowed to use the same nursing diagnoses. a fluid deficit in one patient is a fluid deficit in another patient if the assessment data supports both. you can't really make it anything else unless your supporting assessment data is weak. when that happens you can sometimes play around with wording and backdoor into other nursing diagnoses.
when you are using that alphabetical index of medical diagnoses, diagnostic procedures, clinical states, symptoms and problems from section ii of the ackley/ladwig book it is only giving you suggestions of nursing diagnoses you might be able to use. you still have to go through the legwork of taking your abnormal data and seeing if any of it matches the defining characteristics listed with any of those nursing diagnoses. writing a care plan is very customized and involves critical thinking. if you don't understand how your abnormal assessment data gets turned into defining characteristics that support a nursing diagnosis then, as you now find, you are going to get stuck.
go back through the many different posts on these two threads and read example after example of how i go through the process of choosing nursing diagnoses for students. you will also find links to the specific nursing diagnosis pages on the ackley/ladwig and gulanick/myers online care plan constructors. since you already have the ackley/ladwig book, you might want to see what the gulanick/myers nursing diagnosis pages have on them. i have a copy of both books and i like the gulanick/myers care plan book as much as the ackley/ladwig book.
it all starts with your assessment data. that becomes the foundation of your care plan. if your data is weak, your care plan will suffer for it. your abnormal assessment items become the "defining characteristics" that are the items following the words "as evidenced by" or "as manifested by" in your nursing diagnostic statement. they are also the problems that your nursing interventions address. those same nursing interventions are being done with the idea that you expect something to occur as a result. that something is a goal or outcome. keep in mind that for every action there is a reaction. it is all related.
probably the hardest part of the nursing diagnostic statement is the "related factors". normally, we would like to put a medical diagnosis in their place, but can't. i like to think of some of them as pathophysiology. they are etiologies and give some kind of reasoning as to why the patient's symptoms, or "defining characteristics", have occurred in the first place. sometimes we have to be creative and make up the wording for them because nanda hasn't done it. the ackley/ladwig book is full of these as are other care plan authors books.
with your patient who has osteoarthritis and has had a (total) hip replacement. . .the first things that come to my mind are that this patient has undergone general anesthesia and is a surgical patient even though he/she is also an orthopedic patient. so, all the potential complications of general surgery and general anesthesia need to be assessed for.
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- surgical pain
- nausea/vomiting (paralytic ileus)
you can address some of the issues of infection and patient teaching under a diagnosis of impaired skin integrity
because the patient does have a surgical incision that needs to be monitored and perhaps needs some attention. i would word the nursing diagnostic statement like this: impaired skin integrity r/t surgical invasion
(or surgical incision) aeb xx inch incision on l/r hip
. the nursing interventions are going to be things that i would get from nursing textbooks and throughout the different nursing diagnoses of a care plan book that will include things such as monitoring of the wound for signs and symptoms of infection and inflammation, making sure to note the presence and character of any drainage, assessment for pain (if i can't use an acute pain diagnosis) and instructing the patient in discharge care of the wound. i can kind of back into goals, although, in reality, i already know in my mind what i am trying to accomplish: healing of the wound without infection, comfort from pain, correct knowledge of self-care of the wound by discharge. i merely have to turn them into statements and that is just playing around with words.
goals are "outcomes". i didn't much care for the explanation of outcomes in the ackley/ladwig book so i did some search and research about this subject some time ago in order to clarify for myself what the difference was between a "goal" and an "outcome". what i believe is the correct answer to that question is that:
- outcomes are the predicted results of independent nursing actions.
- goals are the predicted results of collaborative nursing actions.
this older post of mine (http://allnurses.com/forums/1905097-post88.html
) gets more specific about what goes into goals and outcomes statements.
goals and outcomes flow from the related factors of the nursing diagnosis statement and flow with the nursing interventions. one of the reasons instructors have students formulate these 3- (and sometimes 4-) part diagnostic statements is to assist you is seeing how the 3 (or 4) elements fit together in the critical thinking process. in actual workplaces, these elaborate diagnostic statements are not used that often. only the nursing diagnosis is put in the chart. however, in so doing, each nurse is assumed to understand and know what the definition, related factors and defining characteristics, or symptoms, are that qualify using that nursing diagnosis for that particular patient.
getting back to what i'm saying to you about choosing interventions and goals is that you can't depend on them coming from one particular nursing diagnosis page of a care plan book. in reality, you are listing nursing interventions for individual problems that the patient has. now, here is where you need to understand what nursing diagnosis is all about. . .most of the nursing diagnoses are groups of individual problems or symptoms that are related to each other. a good example is "constipation". if you look at the defining characteristics for it you can nod your head and say "uh huh, that's what happens when you're constipated". however, many other nursing diagnoses address a handful of problems or symptoms where some of them are a little vague or they can also belong with other nursing diagnoses. and that, i think, has created a lot of confusion. care plans
were much easier 30 years ago when we could just list
- broken skin on left hip
- can't move arm
- can't move leg
- oxygen saturation of 70
- urine output of only 20cc an hour
nursing diagnoses won't allow us to do that anymore. however, in essence, when you are developing your nursing interventions for a care plan, that is exactly what you have to do, although no one seems to be saying that. it is easier to find nursing interventions for "urine output of only 20cc an hour" in a nursing textbook than it is to find "deficient fluid volume".
i hope i am making sense to you. i started out learning care plans under one system and had to learn how to do them under the nursing diagnosis system and i can see the difference very clearly. you are always addressing the individual problems, symptoms, line item abnormal assessment items
. always. and that comes from your assessment data. all this stuff with the nursing diagnosis and nursing diagnostic statement was fit into this equation long after the writing of care plans was well-established. to do this, you need to have an understanding of the overall problem each nursing diagnosis is addressing. this is why you need to look at the definition of each nursing diagnosis, it's related factors and defining characteristics before using it and decide if it truly applies to your patients situation before using it.