First care plan ever! HELP

  1. medical dx: debilitation
    subjective report: admitted to hospital due to dislocated right hip replacement. this is the third dislocation. patient dislocated hip while rolling in bed.
    significant pmh: anxiety, depression
    prior level of fx: lives with (healthy) husband. amb without a.d. steps up into home.
    present functional deficits: sitting to standing. standing to sitting. sba. bed mobility min

    the physical therapist stated " educated patient on hip precautions. patient able to recal half of precautions on own without cues"

    i did not get to spend much time with this patient and being that it was my first clinical ever i was not sure what to do. i did not have a rn to follow (it was a very small hospital). so needless to say i was in the dark as to what i was supposed to be doing. but from my experience as a tech i knew how to do an initial assessment. this patient was very kind and sweet and talkative. i did not ask the right questions but from my assessment i gathered that when i taught her her hip precautions, i asked her to repeat them back to me and she would always forget one or two.
    it was not until after my initial assessment that i went through her chart and found that she was completely non-compliant.

    i know that this is not enough information but i am using the nursing diagnosis health behavior, risk prone r/t inadequate comprehension.

    all we are required to do for our first care plan is the: nursing diagnosis, supporting data, goal/outcome criteria.
    i keep getting stuck because i am not sure how many supporting datas i need, and i am torn between the goal statements : the patient will begin to make lifestyle and physical changes. or the patient will comply with prescribed treatments.

    please give as much help and advice you can!
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    About BAMAGIRL4911

    Joined: Mar '12; Posts: 4; Likes: 1


  3. by   Esme12
  4. by   Esme12
    the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

    there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) can also use the search on this site to lead you to care plans.


    plan basics:
    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 plan:
    1. 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)
    2. 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)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

    care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

    assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

    care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

    what i would suggest you do is to work the nursing process from step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    would you say the patient has a knowledge deficit about her disease as the basis for non compliance? does she has problem performing adls? does her depression play a role in her non -compliance? has she been screened for substance abuse? physical abuse?

    she is non-compliant therefore it is not a risk, right? so, she is non-compliant r/t....deficient knowledge? coping? depression? she is at risk for falls and injury or damage to hip due to repetitive hip dislocations, right? she is at risk for impairment of skin integrity due to potential falls from the hip, right?

    nanda-i definition: subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf

    deficient knowledge
    nanda-i definition: absence or deficiency of cognitive information related to specific topic
    knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. learning may involve any of the three domains: cognitive domain (intellectual activities, problem solving, and others); affective domain (feelings, attitudes, belief); and psychomotor domain (physical skills or procedures
    ineffective coping
    nanda-i definition: inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources
    for most persons, everyday life includes its share of stressors and demands, ranging from family, work, and professional role responsibilities to major life events such as divorce, illness, and the death of loved ones. how one responds to such stressors depends in part on the person's coping resources. such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources. sociocultural and religious factors may influence how people view and handle their problems. some cultures may prefer privacy and avoid sharing their fears in public, even to health care providers. as resources become limited and problems become more acute, this strategy may prove ineffective
    impaired physical mobility
    nanda-i definition: limitation in independent, purposeful physical movement of the body or of one or more extremities
    alteration in mobility may be a temporary or more permanent problem. most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). mobility is also related to body changes from aging. loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of older patients. restricted movement affects the performance of most activities of daily living (adls). nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment
    nanda-i definition: behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional. in the presence of an agreed-on health-promoting or therapeutic plan, person's or caregivers behavior is fully or partially non adherent and may lead to clinically ineffective or partially ineffective outcomes.
    common related factorsconflicting health values
    health beliefs
    cultural beliefs/influences
    spiritual values
    patient-provider relationships
    health care system barriers
    complexity of therapeutic regimen
    situational low self-esteem
    nanda-i definition: development of a negative perception of self-worth in response to current situation (specify)
    self-esteem is a component of an individual's self-concept. positive self-esteem is based on the person's feeling worthwhile and capable of responding to challenges and stressors. low self-esteem represents a mild to marked alteration in an individual's view of himself or herself, including negative self-evaluation or feelings about self or capabilities. this change in self-esteem is a temporary state in response to feeling unable to manage the current situation. one's self-esteem is affected by (and may also affect) ability to function in the larger world and relate to others within it. self-esteem disturbance may be expressed directly or indirectly.
    risk for impaired skin integrity
    nanda-i definition: at risk for skin being adversely altered
    (gulanick: nursing care plans, 7th edition )

    i hope this helps.

    nursing resources - care plans
    nursing care plans, care maps and nursing diagnosis
    cns: problem oriented nursing care plans
  5. by   AndrewCraigRN
    Why was she non-compliant? What made you come to that conclusion? Was it other nursing or doctor observations? What is the PT? It's my understanding the word "non-compliance" should be used conservatively because of the long effects on insurance and other situations. Does she have neurological problems? Has she been thoroughly educated about her hip problem? It sounds like something isn't "clicking" in her head. Heck, this is her third time. Also, what made you decide on "inadequate comprehension?" Is the non-compliance the barrier to comprehension or is there a physiological (i.e. neurological) problem? Something doesn't seem quite right. What did your physical assessment reveal? Also, what defining characteristics did your patient have for you to determine your diagnoses? Some thought provoking questions hopefully. That confuse you more. Or, thinking about these questions may help you determine if you've chosen the priority nursing diagnoses for her situation. Some other to consider is safety such as, "Risk for falls or Risk for injury."
  6. by   NCRNMDM
    Physiological needs are higher on Maslow's Hierarchy, so they take priority over your diagnosis of Risk Prone Health Behavior. Is this patient in pain r/t the dislocation? Did you assess pain at all during your assessment? How long ago was the last hip surgery? Is this patient still at risk for infection r/t the recent surgical procedure? How does the surgical site look? Did you examine it? Did you do a head to toe assessment? I ask these questions because these diagnoses take higher priority. One of our instructors tells us that pain is the highest priority unless the patient's airway is acutely compromised, they have no pulse, or they are in an imminent pre-arrest situation.

    If you did a head to toe assessment and found something abnormal, it may take higher priority than your diagnosis. For instance, let's say the patient's respiratory rate was 32 breaths per minute upon assessment, or your patient's oxygen saturation was 85, or you heard crackles in the upper lobes and diminished breath sounds overall, then you would be looking at diagnoses like Ineffective Breathing Pattern, Ineffective Airway Clearance, or Impaired Gas Exchange. These diagnoses would take priority over Risk Prone Health Behavior.

    I know this was your first clinical experience, and I know how overwhelming that first day is, but you need to begin developing your assessment and diagnosis skills. Begin to look at the big picture rather than focusing solely on your patient's primary problem. Conduct a thorough head to toe assessment before you even start to think about any diagnoses. Remember, the diagnosis should concur with the evidence you gathered during your assessment. You shouldn't have to engineer data, or stretch your imagination, to be able to apply a diagnosis. If a diagnosis doesn't fit with the data you collected during assessment, then you can't use it.

    If you are going to use Risk Prone Health Behavior, then you will need more evidence than statements of non-compliance in the chart, and some slight forgetfulness. The patient's pain, anxiousness about being placed back in the hospital, and her confusion as to why this replacement has also failed may be barriers to learning, and may explain her forgetting parts of your teaching. You can't immediately label someone with inadequate comprehension after spending a short time with them. I'm not sure how you can apply Risk Prone Health Behavior in this situation, and I'm not entirely sure that it fits.
  7. by   nurseprnRN
    agree c mattstudent23 that there may be higher levels of need for prioritizing, but i like the way you thought about the risk prone behavior due to lack of comprehension. i believe this translates into a safety issue, which is fairly high on the ol' maslow list. absent any other more serious issues i think you could make a very good argument for this being numbah one for this lady. good job.

    and for what it's worth, we no longer think in terms of "compliance." if someone is not following a medical or nursing plan of care (note: the word ""orders" no longer appears in this sentence for a good reason), they may choose not to adhere to it; they are under no obligation to comply with your or the physician's wishes. use "adherence" and you'll be in good company (ajn for one).