HELP with CARE PLAN by tomorrow!!

Columnist · Oct 19, 2012

Moved to Nursing Student Assistance for more response.

DSCCnsg14 · Oct 19, 2012

thank you:)

LiLev · Oct 19, 2012

I am new to care plans myself but my instructor would consider alcaholism a medical diagnosis. To find the etiology of the acute confusion think " what about alcoholism makes the patient confused?"

Like I said, I'm new to nursing as well so I don't know the answer but I would think it would be something like dehydration or impaired circulation (to brain?).

Then again, I could be wrong, just another's 2 cents.

Linda

Esme12, ASN, BSN, RN · Oct 19, 2012

Welcome to AN! The largest online nursing community!

OK lets see how to help

Remember......Do 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? What are the vital signs? What is your patient saying?. 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? What is important for them to know in the future.

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.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. They are listed in the NANDA taxotomy 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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

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. 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.

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: ADPIE

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)

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.

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.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Esme12, ASN, BSN, RN · Oct 19, 2012

So looking at this scenario............

David Micheals lives in an urban senior citizens' apartment complex. He is a 60 year old widower and retired military man with two adult sons whom he says rarely visit. He has been referred to your hospital-based home care unit for follow-up after inpatient treatment from acute pancreatitis. He has been hospitalized three times in 6mons for this diagnosis and denies excessive alcohol use. He says, "I have a few beers every now and then, nothing I cannot handle." You have seen Mr. Micheals on a weekly basis for the past month. He has stated he doesn't know any of his neighbors and never sees his boys. "They never come to see me anymore."
He is pleasant, cooperative, and oriented when you see him and always thinks you for coming to visit. His two-room apartment is usually untidy, but clean, with dishes and glasses in the sink and several plastic trash bags in the kitchen.
Today, when you arrive, Robert, his oldest son, is present and looks angry when you introduce yourself. He tells you Mr. Micheals has always been a drinker, but in the past year or so things have gotten out of hand. "We don't let our kids come over here; we never know what he'll be like. I've tried to get him help, but he won't listen to me. I can't take it anymore." Mr. Micheals is in his bedroom, yelling at and calling for David.
When you enter the room, he is pacing, wringing his hands, and is unable to identify you. He is disoriented to place and time and tell yous "don't step on them bugs" pointing to the patterned rug. He is inattentive when you ask questions about his condition and continues to pace. There are numerous empty beer bottles throughout his apartment. Mr. Micheals becomes increasingly agitated and his son abruptly leaves. After checking his vital signs you notify his physician and arrangements are made to transport him to the hospital. Mr. Micheals is seen in the ER and is admitted to the psychiatric unit for detoxification and treatment.

Looking at this scenario. As the nurse who knows him what would alarm you for this patient......he has had several hospitalizations for acute pancreatitis. What is pancreatitis? What causes it? what are it's symptoms? It is apparent this patient has a recent problem due to the repetitive admissions. Is this patient in denial of their disease? He is isolated from his family. He is retired military.....is this patient self medicating for PTSD or other undiagnosed disorder.http://emedicine.medscape.com/article/181364-overview medscape requires registration but it is free and a great resource/source of information

The patient has an acute alteration in mentation/orientation. He is agitated, confused and hallucinating. What do we know about alcoholism that can cause this presentation. As a nurse we can use our observations to make conclusions about a patients care. Does this patients family show signs of care giver strain.

What causes confusion in the alcoholic? Is this patient in withdraw or is he suffering from alcohol poisoning?

You have chosen acute confusion as you nursing concern and that is the most pressing threat to your patient right now.

What is the NANDA definition of acute confusion.....Ackley: Nursing Diagnosis Handbook, 9th Edition

NANDA-IDefinition: Abrupt onset of reversible disturbances of consciousness attention, cognition, and perception that develop over a short period of time

Defining Characteristics

Fluctuation in cognition, level of consciousness, psychomotor activity; hallucinations; increased agitation; increased restlessness; lack of motivation to follow through with goal-directed behavior or purposeful behavior; lack of motivation to initiate goal-directed behavior or purposeful behavior; misperceptions

Related Factors (r/t)

Alcohol abuse; delirium; dementia; drug abuse, fluctuation in sleep-wake cycle, over 60 years of age, polypharmacy

Suggested NOC Outcomes

Cognition, Distorted Thought Self-Control, Information Processing, Memory

Example NOC Outcome with Indicators

Cognition as evidenced by the following indicators: Communication clear for age/Comprehension of the meaning of situations/Attentiveness/Concentration/Cognitive orientation (Rate the outcome and indicators of Cognition. 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised.)

Client Outcomes Client Will (Specify Time Frame):

Demonstrate restoration of cognitive status to baseline

Be oriented to time, place, and person

Demonstrate appropriate motor behavior

Maintain functional capacity

Suggested NIC Interventions

Delirium Management, Delusion Management

Now lets look at your nursing diagnosis.

"Acute confusion r/t acoholism as evidence by pacing, wringing of hands, disoriented x3, hallucinations, inattentiveness, denial of alcohol abuse, and beer bottles throughout apartment"

Is alcoholism a medical diagnosis? Does it fit into the NANDA definition/defining characteristics and related factors? How woud the statement need to be changed to reflect the NANDA taxonomy?

Acute confusion R/T alcohol abuse/delirium AEB .........

"beer bottles throughout apartment, pacing, wringing his hands, agitation, inability to identify familiar staff, disorientation to place and time and visual hallucinations "don't step on them bugs" pointing to the patterned rug."

See the difference? Does this makes sense? You have done a lot of work......it is well done!.

Look at your care plan does it fit you nursing diagnosis NANDA criteria? Questions?

Mrs.Priss · Oct 20, 2012

Go *****! I came here looking for help with this yesterday! Lol

Esme12, ASN, BSN, RN · Oct 20, 2012

Go Rachel! I came here looking for help with this yesterday! Lol

??? you didn't post did you? I would have helped.

DSCCnsg14 · Oct 20, 2012

We are in the same group :) Thank you so much, going into this completely blind and now to have a grasp on it - Thank you!

DSCCnsg14 · Oct 20, 2012

After you explained NANDA and the differences between nursing diagnosis and medical diagnosis REALLY helps me where to start my nursing care of plan.

The scenerio really caught me off guard when there was no vital signs or other important physcial assessment information.

DSCCnsg14 · Oct 20, 2012

As for the assessment information, (instructor likes using arrows) how do you determine ALL the subjective and objective data. Increased uncleanliness would include is untidy apartment with beer bottles everywhere. For decreased orientation would I need to include (x2) for place and time?

Subj: no alcohol abuse, ↑ hallucinations, ↑ agitiation, ↓ social interaction.

Obj: 60-year-old male, ↑ uncleanliness, ↓ attention, ↓ orientation

Welcome to AN! The largest online nursing community!
OK lets see how to help
Remember......Do 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? What are the vital signs? What is your patient saying?. 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? What is important for them to know in the future.
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.
Every single nursing diagnosis has its own set of symptoms, or defining characteristics. They are listed in the NANDA taxotomy 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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition
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. 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.
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: ADPIE
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)
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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.
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.
Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Esme12, ASN, BSN, RN · Oct 20, 2012

As for the assessment information, (instructor likes using arrows) how do you determine ALL the subjective and objective data. Increased uncleanliness would include is untidy apartment with beer bottles everywhere. For decreased orientation would I need to include (x2) for place and time?
Subj: no alcohol abuse, ↑ hallucinations, ↑ agitiation, ↓ social interaction.
Obj: 60-year-old male, ↑ uncleanliness, ↓ attention, ↓ orientation

Look at your scenario.......it says it there.

David Micheals lives in an urban senior citizens' apartment complex. He is a 60 year old widower and retired military man with two adult sons whom he says rarely visit. He has been referred to your hospital-based home care unit for follow-up after inpatient treatment from acute pancreatitis. He has been hospitalized three times in 6mons for this diagnosis and denies excessive alcohol use. He says, "I have a few beers every now and then, nothing I cannot handle." You have seen Mr. Micheals on a weekly basis for the past month. He has stated he doesn't know any of his neighbors and never sees his boys. "They never come to see me anymore."

He is pleasant, cooperative, and oriented when you see him and always thinks you for coming to visit. His two-room apartment is usually untidy, but clean, with dishes and glasses in the sink and several plastic trash bags in the kitchen.

Today, when you arrive, Robert, his oldest son, is present and looks angry when you introduce yourself. He tells you Mr. Micheals has always been a drinker, but in the past year or so things have gotten out of hand. "We don't let our kids come over here; we never know what he'll be like. I've tried to get him help, but he won't listen to me. I can't take it anymore." Mr. Micheals is in his bedroom, yelling at and calling for David.

When you enter the room, he is pacing, wringing his hands, and is unable to identify you. He is disoriented to place and time and tells you "don't step on them bugs" pointing to the patterned rug. He is inattentive when you ask questions about his condition and continues to pace. There are numerous empty beer bottles throughout his apartment. Mr. Micheals becomes increasingly agitated and his son abruptly leaves. After checking his vital signs you notify his physician and arrangements are made to transport him to the hospital. Mr. Micheals is seen in the ER and is admitted to the psychiatric unit for detoxification and treatment.

Then go back to NANDA and look for features and outcomes......they give the general idea and you apply them to your scenario. are you only to pick one diagnosis?

Suggested NOC Outcomes

Cognition, Distorted Thought Self-Control, Information Processing, Memory

Example NOC Outcome with Indicators

Cognition as evidenced by the following indicators: Communication clear for age/Comprehension of the meaning of situations/Attentiveness/Concentration/Cognitive orientation

(Rate the outcome and indicators of Cognition. 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised.)

Client Outcomes........ Client Will (Specify Time Frame):