Desperately need help with careplans - page 9

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  1. by   bld24
    I'm having a problem stating a proper Nursing Diagnosis. This is the only part of the care plan I'm having issues with. For some reason my brain is just not getting this. For instance I have a client this week that has a dehisced wound on her abdomen that is infected. The wound was caused by surgical removal of a portacath secondary to infection.

    So I've got the first part of a Ndx: Impaired skin integrity r/t--- then I go blank on what to write.

    Now I know her skin is impaired due to a surgical procedure that was done due to an infection.

    Can someone help me with the proper way to write this Ndx?

  2. by   bookwormom
    How about:

    Surgical recovery, delayed
    --r/t (not specified by NANDA) but dehiscence and infection would seem to fit
    --aeb evidence of interrupted healing of surgical area

    Wilkinson notes that this nurs dx is not fully developed, but I like it.
  3. by   Daytonite
    Quote from bld24
    i'm having a problem stating a proper nursing diagnosis. this is the only part of the care plan i'm having issues with. for some reason my brain is just not getting this. for instance i have a client this week that has a dehisced wound on her abdomen that is infected. the wound was caused by surgical removal of a portacath secondary to infection.

    so i've got the first part of a ndx: impaired skin integrity r/t--- then i go blank on what to write.

    now i know her skin is impaired due to a surgical procedure that was done due to an infection.

    can someone help me with the proper way to write this ndx?

    the actual writing of the nursing diagnosis statement is based on the correct language, or words to use as well as correctly expressing each part of what the diagnostic statement is supposed to contain. the 3-part nursing diagnosis statement follows this format: pes, where p = problem, e = etiology (or cause), and s = symptoms. by the nanda-i (north american nursing diagnosis association, international) guidelines that means writing the nursing diagnostic statement as:
    the nursing diagnosis [problem]--related factor(s) [etiology, or cause]--defining characteristics [symptoms]
    most people are pretty good at putting together a list of the patient's symptoms and usually at picking the nursing diagnosis. the bigger problem is that dog gone "related factor", or etiology, which is where you drew your blank. this part of the process involves some thinking since the words you choose are important--and no medical diagnoses are allowed, usually. you need to take your group of symptoms and ask yourself, "what do they all have in common as the cause of this patient's problem?" the people at nanda-i did a lot of this thinking for nurses over the years because this part of the process has been a real stickler. this is sometimes where nursing care plan books and nursing diagnosis books can help you out since they've already worked up some of these things for you.

    actually, in reading your post, i saw that you had the elements for the r/t part of your diagnostic statement right in front of you, but you weren't seeing them for what they were. looking at my nanda resource for this diagnosis wasn't a lot of help, for the actual wording to use, that is. however, the good thing about nanda is that they encourage creativity with writing these things. so, let me help you out.
    • nursing diagnosis (problem) = impaired skin integrity
    • related factor (etiology, cause) = open surgical wound on abdomen
    • defining characteristics (symptoms) = [this part of the statement is the actual abnormal data assessment items you collected. they will be things such as the description of the wound and character of any drainage, results of any culture and sensitivity done of any exudates. in other words, the definition of this diagnosis is altered epidermis. what are you observing or have found in the medical record of this patient that has led you to the conclusion that she has altered epidermis, keeping in mind that wound dehiscence and infection are what are the underlying cause?]

    put all three elements together and you have your nursing diagnostic statement.
    impaired skin integrity r/t open surgical wound on abdomen aeb [defining characteristics, or symptoms]
    to carry this two more steps farther (for others who are reading this), goals, or outcomes, are based on turning around the problems and symptoms. nursing interventions are developed for each of the defining characteristics, or symptoms, listed under each nursing diagnosis.

    hope that has given you some help.
  4. by   saltlake
    Purchase the book called "All-in-ONE CARE PLANNING RESCOURSE" It cover; Medical-surgical, pediatric, Maternity, and psychiotric Nursing Care Plans. It 's author is Swearingen and it's IBS is: 0-232-01953-6. It should cover anything you would need to know.

  5. by   Daytonite
    Quote from rkdlpn
    I need to see a care plan !
    There are plenty of links to samples of care plans posted here on this thread. You are not always going to find samples of student care plans. I think the main reason is because of the fear of plagiarism. No one wants their hard work to be stolen. Not only that, but there is a patient privacy element to consider as well. The nursing care plan books that are organized by medical diagnosis contain care plans that almost always also include the rationales for the nursing interventions which is probably one of the things you are interested in seeing. Nursing Diagnosis Handbook: A Guide to Planning Care, 7th Edition, by Betty J. Ackley and Gail B. Ladwig includes rationales for the nursing interventions under each nursing diagnosis and extensive references for each rationale. Some of these are also posted on their care plan constructor site. The links to these constructor sites are included in this thread on post #92. Each of these online care plan constructor sites (the Ackley/Ladwig site and the Gulanick/Myers site) contain 50+ different nursing diagnoses pages. Each nursing diagnosis page has much of the same information that is in each authors book. The constructor sites themselves are also meant to format the information you choose or input into a skeleton form which you then print out. Most nursing schools, however, require a much more comprehensive format than what these constructor sites have to offer. The major information I see in them is the actual nursing diagnosis information from their books which is offered online for free.

    There are a number of Internet website links where you can view care plans. They are posted on this thread in the following posts: #20, #26, #34, #35, #56, #78 (case studies), #113. Go to those posts, click on the links and you will be taken to those sites to view those care plans.

    There is a great deal of information about writing care plans and about care plans, in general, on this thread. Many have contributed to it to make it so. Please, take the time to review the information available to you here. There are some real gems of information that will help you tremendously in understanding the care plan writing process. I would also encourage you to post any questions you have about care plans or a specific care plan you are working on. Questions about care plans are posed all the time on this particular forum, not this thread in particular.
  6. by   Daytonite
    here are links to the 75 nursing diagnoses that are currently in the elsevier care plan constructor companion website for nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig. each of these pages contains the nanda definition, outcomes, nursing interventions and references. there are currently 188 nanda-i officially approved nursing diagnoses (per nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international, page ix), so this list is hardly inclusive. however, it does contain the nursing diagnoses most commonly used in the medical/surgical areas of the acute hospitals and in nursing homes.
    001 activity intolerance
    002 ineffective airway clearance
    003 latex allergy response
    004 risk for latex allergy response
    005 anxiety
    006 risk for aspiration
    007 risk for impaired parent/infant/child attachment
    008 disturbed body image
    009 bowel incontinence
    010 ineffective breastfeeding
    011 ineffective breathing pattern
    012 decreased cardiac output
    013 caregiver role strain
    014 impaired comfort
    015 impaired verbal communication
    016 parental role conflict
    017 acute confusion
    018 chronic confusion
    019 constipation
    020 ineffective coping
    021 compromised family coping
    022 ineffective denial
    023 diarrhea
    024 disturbed energy field
    025 adult failure to thrive
    026 risk for falls
    027 dysfunctional family processes: alcoholism
    028 fatigue
    029 fear
    030 deficient fluid volume
    031 excess fluid volume
    032 impaired gas exchange
    033 grieving
    034 anticipatory grieving
    035 dysfunctional grieving
    036 delayed growth and development
    037 ineffective health maintenance
    038 hopelessness
    039 hyperthermia
    040 functional urinary incontinence
    041 total urinary incontinence
    042 risk for infection
    043 risk for injury
    044 deficient knowledge (specify)
    045 readiness for enhanced knowledge (specify)
    046 impaired memory
    047 impaired physical mobility
    048 nausea
    049 imbalanced nutrition: less than body requirements
    050 imbalanced nutrition: more than body requirements
    051 impaired oral mucous membrane
    052 acute pain
    053 chronic pain
    054 impaired parenting
    055 risk for peripheral neurovascular dysfunction
    056 post-trauma syndrome
    057 powerlessness
    058 impaired religiosity
    059 bathing/hygiene self-care deficit
    060 feeding self-care deficit
    061 risk for situational low self-esteem
    062 disturbed sensory perception specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory
    063 impaired skin integrity
    064 disturbed sleep pattern
    065 spiritual distress
    066 risk for suicide
    067 delayed surgical recovery
    068 impaired swallowing
    069 ineffective therapeutic regimen management
    070 disturbed thought processes
    071 impaired tissue integrity
    072 ineffective tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral
    073 impaired urinary elimination
    074 urinary retention
    075 wandering
  7. by   Daytonite
    here is a link to the page that contains links to the 42 nursing diagnoses that are currently in the elsevier care plan constructor companion website for nursing care plans: nursing diagnosis and intervention, 6th edition, by meg gulanick and judith l. myers. each of these pages contains the nanda definition, outcomes, and nursing interventions.
    in addition, there are three more nursing diagnosis pages that you can also link into:
    Last edit by Daytonite on Mar 9, '07
  8. by   skyranger
    Here is a care plan software for PC
    This is fully functional demo version - easy to use and saves time.
    Can be downloaded from
  9. by   Daytonite
    Hi, negrita!

    The care plan process always starts with the data that you have collected (Step #1 of the nursing process). From that data you make a list of the abnormal, or the things you discovered that are not normal. These things become the symptoms, or patient's defining characteristics (NANDA language), that will help you to determine that Impaired Skin Integrity is the correct nursing diagnosis to be using (Step #2 of the nursing process).

    Please list these abnormal symptoms for me, so I can help you with this.

    Welcome to allnurses!
  10. by   Daytonite
    Quote from negrita
    Ct had a femoral/poplital bypass. client past helath history is HTN And DVT.
    I don't think you are understanding me. What you have responded with are medical diagnoses. This is of no help. A care plan addresses the problems your patient has. These problems are based upon abnormal assessment data, not medical diagnoses. For example, since the patient had a femoral/popliteal bypass I would assume that there is an incision. Are there any problems with the incision? Does the patient currently have any open skin ulcers on the affected lower limb? If so, what is the description of them? Is there any pedal or lower leg edema? Any changes in sensation? Did you assess the patient's ability to perform ADLs? Can the patient walk? The answers to these questions are potential abnormal assessment data that need to be known in order to design and work nursing interventions into a care plan. While Impaired Skin Integrity is one possible diagnosis there is a possibility based on the little bit of medical diagnosis information you have supplied that the patient might also have Ineffective Tissue Perfusion, peripheral and Decreased Cardiac Output. However, I can't verify that without knowing your assessment data. Is this a real patient or a non-existent subject of a case study assigned by your instructor?
  11. by   nursey23
    i would like to but we were just given this situation :

    patient name (age, religion, location) was admitted at the hospital due to multiple fracture and lacerations after an mva. 1 hr pta, pt was with her bf driving along the highway at 150 kph when suddenly, her bf lost control of the motorbike.

    patient was thrown 15 m away. residents near the accident site brought them to the er. her bf was pronounced doa while patient was rushed to or. upon initial visit to patient, you observed that both legs have casts. multiple lacerations and contussions are observed on her fae and all over her body. patient doesnt want to eat or talk to anyone. she wasnt able to take anything by mouth since her operation. V/S revealed

    t - 38.6
    p - 95 bpm
    r - 19 cpm
    bp - 130/90

    for certain, the patient has the following probs - she cant move, she won't eat (im uncertain as to whether how long it has been between her operation and the 'today' of the situation and whether she has an IV or not and whether this would be enough for the moment to sustain her nutritional needs) and she has a fever.

    given that situation, we are supposed to come up with a care plan and a discharge plan.
  12. by   Daytonite
    in your original post you asked for help with the nursing diagnoses and which ones should be listed (focused upon) first.

    this patient has sustained a major trauma, has had surgery and suffered a major personal loss with the death of her boyfriend. the first step in writing a care plan is to assess your patient. assessment data has been given to you in the information provided. from the scenario, i have isolated the following abnormal data (problems):
    • multiple fractures
    • multiple lacerations
    • multiple contusions on her face and body
    • both legs have casts
    • patient doesn't want to talk to anyone (assume this is an indication of her grief over the death of her boyfriend)
    • wasn't able to take anything by mouth since her operation (this could be due to nausea from the anesthesia, an unknown injury in the accident you weren't told about, or grief over the loss of her boyfriend)
    • temperature of 38.6 degrees (elevated)
    • pulse 95
    • b/p 130/90 (slightly elevated)
    • pain [i've added this because it's reasonable to anticipate that the patient will have pain because of her injuries]
    in step 2 of the care plan process you need to match these problems, or symptoms, with defining characteristics of nursing diagnoses that will apply to this patient. to do that you need your nanda nursing diagnosis reference book to confirm that you are matching these items to the correct nursing diagnoses. these are nursing diagnoses that will fit with these symptoms in the sequence of importance:
    • imbalanced nutrition: less than body requirement r/t lack of interest in food aeb wasn't able to take anything by mouth since her operation
    • impaired tissue integrity r/t traumatic injuries aeb multiple lacerations and multiple contusions on her face and body
    • hyperthermia r/t trauma aeb temperature of 38.6 degrees
    • impaired physical mobility r/t immobilization of legs aeb multiple fractures of bones with casts on both legs
    • acute pain r/t traumatic injuries aeb elevated blood pressure and heart rate [patient would also be reporting she was having pain]
    • grieving r/t death of boyfriend aeb patient doesn't want to talk to anyone
    • risk for infection r/t traumatic tissue injuries
    • risk for injury r/t immobility [thinking of the potential to develop a dvt here]
    now, that all the problems (defining characteristics) have been divided up and placed with nursing diagnoses, the next step is to develop goals and nursing interventions for them. so, you need to look in your nursing textbooks to find nursing care for:
    • ways to encourage the patient to eat
    • lacerations and contusions
    • care of a patient with a fever
    • an extremity with a cast, care of the cast
    • interventions for the patient having pain
    • how to help the patient deal with her grieving at the loss of her boyfriend and the emotional burden she has at this time
    • actions you will need to take to avoid the patient developing an infection of any of her wounds
    • actions you will need to take to help prevent the development of a dvt in her legs that have casts on them
    since this patient also underwent surgery a few other potential problems should be observed for and prevented:
    • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
    • urinary retention
    • constipation
    • nausea/vomiting (due to paralytic ileus)
    if you like, you can work them into the nursing diagnoses as other "risk for" diagnoses.
    Last edit by Daytonite on May 13, '07
  13. by   Daytonite
    can someone help me to create nursing diagnoses for asthmatic patients?
    the first step in choosing a nursing diagnosis involves assessing the patient. any nursing diagnosis is always based upon the signs and symptoms the patient is having. these signs and symptoms are abnormal assessment items. depending on how thorough your assessment of the patient is will determine how well your care plan is going to attend to the patient's problems.

    with asthma, the patient is, in general, going to have these symptoms in order as an asthma attack worsens:
    • hacking, non-productive cough (due to bronchial edema)
    • restlessness
    • diaphoresis
    • only able to speak in short, broken phrases
    • eventually the cough become productive of frothy, clear sputum
    • breathlessness
    • chest tightness
    • dyspnea (shortness of breath)
    • use of accessory respiratory muscles
    • hyperresonance
    • tachycardia
    • some mild systolic hypertension
    • inspiratory and expiratory wheezes
    • crackles (as spasm and obstruction worsen)
    • prolonged expiratory phase of respiration (due to bronchospasm)
    • mucusal edema
    • mucus plugging with mucus trapped behind airways that are narrowed or occluded
    • diminished breath sounds
    • cyanosis, lethargy, confusion and hypoxemia (as the patient proceeds to status asthmaticus or respiratory failure)
    based upon one or more of these above symptoms being present, nursing diagnoses that would be appropriate to use, in priority order, would be:
    • gas exchange (abnormal skin color, confusion, cyanosis, diaphoresis, shortness of breath, hypoxemia, tachycardia, abnormal blood gases) - this diagnosis is generally used when there is hypoxia, hypoxemia or the patient is getting close to it
    • ineffective breathing pattern (alterations in the depth of breathing, shortness of breath, orthopnea, prolonged expiratory phase of expiration, use of accessory respiratory muscles to breathe) - the act of breathing is not providing enough air
    • ineffective airway clearance (any kind of cough, ineffective cough, any kind of adventitious breath sounds, any kind of changes in the rate or rhythm of the respirations, difficulty speaking due to breathing impaired, excessive sputum production) - this diagnosis is when the person is having difficulty clearing secretions from the respiratory passages in order to maintain a clear airway
    • fear (fear of suffocation or death) - threats to the self that the patient recognizes as dangerous
    • anxiety (obsessive tinkering with oxygen equipment, over attention to medication, treatment, physical symptoms) - warnings of impending danger causing patient to take measures to deal with threats
    examples of a nursing diagnostic statements using the above nursing diagnoses for an asthmatic patient might be:
    • impaired gas exchange related to alveolar-capillary membrane changes as evidenced by cyanosis, lethargy, confusion and hypoxemia
    • ineffective breathing pattern related to fatigue as evidenced by prolonged expiratory phase of respiration, shortness of breath and the use of accessory respiratory muscles to breathe.
    • ineffective airway clearance related to airway spasm as evidenced by diminished breath sounds with inspiratory and expiratory wheezes and shortness of breath.
    • fear related to threat of suffocation as evidenced by increased excitement and statements of "i'm not getting enough air!"
    • anxiety related to fear of suffocation as evidence by patient constantly checking to make sure oxygen tubing is correctly positioned and asking what the setting of the oxygen flow is.
    it would be very useful to have a book of nursing diagnoses or care plans that include the nanda definitions, defining characteristics and related factors since nanda is very specific about how each of the nursing diagnoses should be used.