the writing of a nursing care plan is the documentation of your critical thinking process in solving the patient's nursing problems. you use the nursing process to determine what those problems (nursing diagnoses) are and then to create interventions to do something about them. there are 5 steps to the nursing process and specific things must be done in each of those steps before moving onto the next:
- 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.
- 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 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
your major problem with writing this care plan for this patient with medical diagnoses of chronic renal failure and pulmonary congestion is that you must organize all the abnormal data you have collected (see step #2 of the nursing process).
- low rbc and hemoglobin
- rbcs and wbcs in urine
- blood in stool
- elevated creatinine of 875.8 umol/l
- patient has financial problems
this data is used to help determine what the patient's nursing diagnoses are. you need a nursing diagnosis reference to help.
- it is very likely that this patient has decreased cardiac output [related to altered afterload because of the symptom of dyspnea and the medical diagnosis of pulmonary congestion. it would be helpful to know if there are other symptoms.] [color=#3366ff]decreased cardiac output
- ineffective breathing pattern [because of the dyspnea] ineffective breathing pattern
- deficient fluid volume [because this patient is losing blood - low rbc and hemoglobin, blood in stool] deficient fluid volume
- impaired urinary elimination [because this patient is on dialysis and has an elevated creatinine of 875.8 umol/l] [color=#3366ff]impaired urinary elimination
- ineffective health maintenance [this will be related to insufficient financial resources since the patient will be unable to be able to get the health care they need without the money to pay for it] [color=#3366ff]ineffective health maintenance
- risk for infection [it is not diagnosed by the doctors, but likely that this patient has a urinary tract infection because of the rbcs and wbcs in the urine and the impaired immune system response because of the chronic renal disease] [color=#3366ff]risk for infection
this list of nursing diagnoses cannot help you if you do not read about the medical conditions that this patient has. you need to learn about the pathophysiology, signs/symptoms, usual tests ordered, the medical treatment that the doctor is going to order for the medical disease or condition that the patient has, the medical procedures that are likely to be performed, their expected consequences during the healing phase, and any potential complications. compare all this information to what has been done to your patient already and what you assessed in the patient. did you overlook anything?
- chronic renal failure
- pulmonary congestion
- metabolic acidosis