Help with my care plan!

  1. Hi all, new to this site, and starting on my first care plan and im having a lot of trouble doing it..
    so far I have as follows:

    nursing dx: Impaired mobility

    related to: deconditioning

    aeb: Patient had limited ROM when assisting with bed bath

    ... now, i dont understand what the secondary to part is... is the secondary to, something that happened as a result of the nursing dx?
    if that's the case, the pt. was admitted with a Deep vein thrombosis, so could that be a secondary to?

    lastly, i need a short term goal, and long term goal for the pt.... and im having a real tough time trying to figure out a measurable specific goal that can be reached...

    thank you in advanced!!
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    About metallicaman1031

    Joined: Feb '13; Posts: 16; Likes: 10


  3. by   Esme12
    Welcome to AN! The largest online nursing community!

    We are happy to help with homework but we will not do it for you.......we will lead you to the best way for you to answer it yourself.

    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:


    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)

    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 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.

    So tell me about your patient.......What do they need? What do they c/o? ? What is your assessment......What does this tell me about the patient?
    Last edit by Esme12 on Feb 21, '13
  4. by   Esme12
    A care plan is a determination of the patient's nursing problems and strategies to solve them. In order to do that...... we employ a tool called the nursing process to help us. Follow the 5 steps of the nursing process in the sequence that they occur, you will be able to write a care plan. the first order of business is to collect as much data about the patient as you can.

    step 1 assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

    step 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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
    • your instructors might have given it to you.
    • you can purchase it directly from NANDA. NANDA I nursing diagnoses: definitions & classification published by NANDA I.
    • many authors of care plan and nursing diagnosis books include the NANDA nursing diagnosis information. I use Ackley: Nursing Diagnosis Handbook, 9th Edition

    :p (problem, or nursing diagnosis) + e (etiology, or cause of the problem) + s (symptoms, the patient's response to their medical illness, or what NANDA calls defining characteristics)
  5. by   blackvans1234
    Dx: Poor exam grades Secondary to not studying AEB exam grade of 58

    Dx (what you say) Secondary (What caused it), AEB (Proof of your actual DX)
  6. by   nurseprnRN
    Quote from blackvans1234
    Dx: Poor exam grades Secondary to not studying AEB exam grade of 58

    Dx (what you say) Secondary (What caused it), AEB (Proof of your actual DX)
    Perfect example, and so succinctly stated. Gold star, blackvans1234.

    When you look at the NANDA-I 2012-2104 (which you should have even if your faculty forgot to put it on the bookstore list; free 2-day shipping for students), you will find the terms defining characteristics (in this case,= the "58," because that grade is in the range of the definition of failing), and the related factors (in this case, the "secondary to," "due to," "caused by," = the "not studying." This would be something you would determine by assessment. Perhaps it was caused by not studying; perhaps it was caused by the fact that the student was caught cheating and had to turn in her paper before it was finished, or because she was not allowed the xtra time for test-taking per her IEP, or because she filled in the bubbles on the form out of order... you make the call)

    The defining characteristics for any nursing diagnosis are your assessment data that made you decide that was the correct diagnosis. In medical diagnosis, that might be something like diagnosing anemia because of the results of a lab test, or tuberculosis because of the results of a chest xray and sputum analysis. In nursing diagnosis, the data are listed in NANDA-I as defining characteristics-- the data that define the diagnosis.

    The NANDA-I related factors are the causes of those data. For a medical diagnosis example, you might see anemia (low hemoglobin and hematocrit) after traumatic blood loss replaced with normal saline. In nursing diagnosis, a medical diagnosis MIGHT be a cause of the things you have assessed-- for example, impaired urinary elimination might be related to a urinary tract infection (a medical diagnosis). Or it might be something else that is patient-specific but not directly tied to the patient's medical diagnosis.

    I know this whole concept is big, but it is not optional-- learning to think like a nurse by making nursing assessments and diagnosis is the heart of what we do, and you will learn it (you VILL learn dis or else!) if you work at it. Get the NANDA-I 2012-2014, because with it you will never go wrong and you will learn to think like a nurse faster than your classmates. (You're welcome! )