Help on care plan for primary & secondary dx

pmabraham, BSN, RN · Mar 9, 2013

Good day:

See https://allnurses.com/nursing-student-assistance/care-plan-heparin-819184.html#post7206003

While I'm not yet in nursing school, I appreciate the experienced nurses sharing that care plans and nursing diagnosis is about the nurses assessment (not the medical diagnosis).

Now, if I was in nursing school, and the focus had to be about the medical diagnosis, I would try to get an assessment and then use NANDA.

Thank you.

Esme12, ASN, BSN, RN · Mar 9, 2013

My care plan patient has multiple dx, and I am not sure which one would be considered a primary and then secondary. Admission MD dx:hypoxemia,potential sepsis, diffuse edema, left leg swelling, obtundation, anemia.
Also included are: End stage kidney disease secondary to diabetes and hypertension.
He is on dialysis 3x week, He has a rt partial foot amputation. He came to the hospital due to a left foot unhealing wound that went sepsis, they amputated his left lower leg at calf, and will be going back to surgery in a few days to half more cut off, so its a below the knee amputation. He has hx of MRSA, so on contact isolation.
I know my care plan has to focus on the primary medical dx, but not positive what that may be. Would it be DM, and then secondary would be end stage kidney disease or CRF?
I am really lost. My focus on nrsg dx is more about his inability to move & cope with this, but I don't think an amputation is a primary med dx. I have to make a concept map of the primary dx as well. SO I am stuck until I figure out the primary dx.
Any advice would be soooooooo helpful. It figures I end up with the most difficult care plan pt(at least he is sweet).

Yourcare plan doesn't start with the medical diagnosis. Your care plan is not based on the medical diagnosis....it is based on your assessment of the patient needs.

It is necessary to have a good care plan book. I use Aclkey. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

What care plan book do you have?

Care plans are all about the assessment.....of the patient. The is not enough information here for us to help. Tell me about your patient, What is your assessment? What do they NEED? What is their main complaint? What are their co-morbidities? How old is this patient? What is their base line? What meds are they on?

YOU MUST have a good care plan book with the NANDA diagnosis and it defining characteristics.

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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 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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to 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. 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.

THese sheet may help you out.....daytonite made them (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

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.

Now....tell me about your patients assessment...what do they NEED right now.

jgtdolphin · Mar 9, 2013

Maybe I wasn't very clear on my post, sorry;( I know the nrsg dx part of the care plan. However, under the H&P I have to write in the medical primary and secondary dx. Then make a concept map on the primary dx of that patient. I have several nursing dx from my assessment, but I am really stuck on which would be considered the primary dx. I am thinking its ERSD, and then the risk factors would be DM & HTN. But then I think that DM should be primary. I hope I explained it better. Thanks for all the input.

Esme12, ASN, BSN, RN · Mar 9, 2013

You already gave yourself your answer....

End stage kidney disease secondary to diabetes and hypertension

so the patient has had diabetes and hypertension that has lead to CRF.

Which disease came first that was the catalyst to subsequent disease processes. As case of which came first the chicken or the egg.

First there are a few questions....how long has the patient been diabetic? Are they on insulin? How has the diabetes affected the kidney's? Has this lead to HTN? Could diabetes cause HTN? How has this contributed to this patients disease process?

Look up diabetes.....Diabetes - MayoClinic.com

Look up complications of diabetes...Type 1 diabetes: Complications - MayoClinic.com

Look up Diabetes and renal failure: and Kidney Disease (Nephropathy) - American Diabetes Association

Your patient has diabetes that has lead to renal failure which has lead to fluid imbalances and HTN. Diabetes causes delay in healing and damages arteries and veins which has caused an ulcer that failed to heal and became infected that lead to sepsis that lead to the patient requiring an amputation.

Does that make sense? Maybe your care plan needs a different priority focus? Did you pick the nursing diagnosis that you wanted first then find the evidence? Is the patients ability to cope with the amputation the MOST important to this patient as he faces another amputation caused by delayed healing? Although the loss of a limb is devastating...what is a bigger threat to his life right now?

To help you with formatting and ideas these may be helpful as well.

Concept Mapping Homepage

http://faculty.ucc.edu/nursing-villanueva/Med-Surg Concept Map example.pdf

http://www.austincc.edu/adnfac/collaorative/onsite_conceptmap.htm