i need help-

Esme12, ASN, BSN, RN · Dec 12, 2012

Are you in the US? I am assuming that you are not......Ok. In the US we have care plan books...they use certain terminology. It is called NANDA, North American Nursing Diagnosis Association. Now I know there is NANDA-I which is international. Do you follow this format?

According to what I know.........

planning (write measurable goals/outcomes and nursing interventions)
- goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  - improve the problem or remedy/cure it
  - stabilize it
  - support its deterioration
  - and a goal statement

[*]interventions are of four types

assess/monitor/evaluate/observe (to evaluate the patient's condition)
- note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
[*]care/perform/provide/assist (performing actual patient care)
[*]teach/educate/instruct/supervise (educating patient or caregiver)
[*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation is initiating the care plan

http://www06.homepage.villanova.edu/elizabeth.bruderle/1103/nursingprocess.htm

Look here as well....https://allnurses.com/nursing-student-assistance/student-resources-nursing-424826.html

fitore · Dec 12, 2012

no im from europe. thanks for your help, based in that you said those that i have write belongs to planning phase, but when i write a ncp, should i write always an action and under that rational, in planning phase

classicdame, MSN, EdD · Dec 12, 2012

a plan is something you think about

an intervention is something you do. It is an action.

When you plan, you are thinking about what could you do to help the patient. Once you have decided the best action (plan) then you work the plan. The work is implementation. You are implementing the plan, or putting action to your thinking.

I hope this helps. I know it must be difficult to think in another language. Good luck to you!

Esme12, ASN, BSN, RN · Dec 12, 2012

you may also like these resources...... i hope this helps. Do yo use NANDA?

nursing care plan | nursing crib

nursing resources - care plans

understanding the essentials of critical care nursing

http://www.delmarlearning.com/compan.../apps/appa.pdf

cns: problem oriented nursing care plans

fitore · Dec 12, 2012

I really thank all of you for the help, I watched the web- sites and helped me very much.

But the problem is that: I taught that nursing process has 5 phases : Assess, diagnose, plan, implement, evaluate.

And in many ncp. that I watched those weren't divided like this, and this makes a problem for me because I'm not sure which belongs to who..

ex...

[TABLE]

[TR]

[TD]Assessment[/TD]

[TD]Nursing DX/Clinical Problem[/TD]

[TD]Client Goals/Desired Outcomes/Objectives[/TD]

[TD]Nursing Interventions/Actions/Orders and Rationale[/TD]

[TD]*I[/TD]

[TD=colspan: 2]Evaluation[/TD]

[/TR]

[TR]

[TD]Goals[/TD]

[TD]Interventions[/TD]

[/TR]

[/TABLE]

or others have only

[TABLE]

[TR=bgcolor: #666666]

[TD][ Problem[/TD]

[TD]Outcomes[/TD]

[TD]Nursing Orders[/TD]

[/TR]

[/TABLE]

this makes me confuse

and my question:

outcomes is the planning phase .

Actions/rationale ? ......is this the implement phase?

Esme12, ASN, BSN, RN · Dec 13, 2012

Ok....do you have a care plan book? This might be easier if you give us the example of you patients assessment/case scenario. Your school also might require you to follow a set format which in the Us is frequently this one.....[TABLE=class: cms_table]

[TR]

[TD]Assessment[/TD]

[TD]Nursing DX/Clinical Problem[/TD]

[TD]Client Goals/Desired Outcomes/Objectives[/TD]

[TD]Nursing Interventions/Actions/Orders and Rationale

[/TD]

[TD]*I[/TD]

[TD=colspan: 2]Evaluation[/TD]

[/TR]

[TR]

[TD]Goals[/TD]

[TD]Interventions[/TD]

[/TR]

[/TABLE]

Here is what I know.....Let the patient/patient assessment drive your diagnosis. 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 assessment. 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 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. 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 (ex: CVA/stroke/)aphasia is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Impaired Verbal Communication, pressure damage, decreased circulation to brain in speech center informational sources

Impaired Verbal Communication, Recent stroke, alteration of central nervous and decrease in circulation to brain

Esme12, ASN, BSN, RN · Dec 13, 2012

Simply put......you, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids. For example......from a dear contributor.....Daytonite(RIP)

You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "What's wrong?" You're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it........a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. What

you have just done is step #1 of the nursing process--performed an assessment

. You determine that you have a flat tire. Yo

u have just done step #2 of the nursing process--made a diagnosis.

The " little squirrel" starts running like crazy in the wheel up in your brain as you begin to think.... "What do i do?" You are thinking.......you could call for help. No, you can save the money and do it yourself....or.....You can replace the tire by changing out the flat one with the spare in the trunk. Good thing you took that class in how to do simple maintenance and repairs on a car!

You have just don

e

step #3 of the nursing process--planning (developed a goal and intervention)

. You get the jack and spare tire out of the trunk, roll up your sleeves and get to work.

You have just done step #4 of the nursing process--implementation of the plan

. After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive.....good......everything seems fine. The spare tire seems to be OK and off you go and on your way.

You have just done step #5 of the nursing process--evaluation (determined if your goal was met).

Can you relate to that? Does that help and make sense? That's about as simple as I can reduce the nursing process for you to understand....... but, you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.

Esme12, ASN, BSN, RN · Dec 13, 2012

Nursing Care Plan

(Correlation Chart)

[TABLE]

[TR]

[TD]ASSESSMENT[/TD]

[TD]ANALYSIS[/TD]

[TD]PLANNING[/TD]

[TD]IMPLEMENTATION[/TD]

[TD]EVALUATION[/TD]

[/TR]

[TR]

[TD][/TD]

[TD]NURSING DIAGNOSIS[/TD]

[TD]GOALS[/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Subjective:

What the patient says, the family, the doctor, a nurse/

Usually in quotations

**Note if your patient is nonverbal, you can still have subjective data from other sources.

Objective: (Note your Topics to the side)

Start with a brief overview of the patient.

Example: 78 yo white male admitted 6/12/09 with COPD exacerbation

PMH: include a comprehensive past medical history of your pt

Orders: orders that are specific to your ND or that may contribute to supporting your ND statement

Interdisciplinary assistance such as PT, OT, RT
Diet
Activity
Oxygen

Radiology: report any radiological findings that may support or contribute to your ND statement

Labs: what laboratory findings are pertinent to supporting your ND statement

Medications: only medications that can support your ND statement

Assessment findings: can include an array of things, but only if relevant to support

Intake and Output: include if can support your ND
Vital Signs: usually a great inclusion to support most ND
Wound appearance
Mobility performance
System Assessment: that is pertinent to your ND

Example; Impaired Gas Exchange-do Resp assessment

[/TD]

[TD]P= Problem

E=Etiology

**May use Secondary to a diagnosis after the etiology if it permits

S=Signs and Symptoms

****Note that if it is a Risk for diagnosis you will only have a PE format without signs and symptoms[/TD]

[TD]PATIENT WILL.....

This is what the nurse hopes to achieve by implementing the nursing interventions

COMPONENTS

Subject: PT will

Verb: action patient is to perform

Condition: explains how the behavior is to be performed

Criteria: Time frame

BE SPECIFIC

Patient will increase mobility by the end of 3-11 shift as evidenced by independently ambulating to chair.[/TD]

[TD]NURSE WILL.....

This is what the nurse will do to assist the patient in accomplishing the goal.

COMPONENTS

Subject: Nurse will

Action verb: precision--educate, demonstrate administer

Content: the what and where of the order

Time Element: when, how long, or how often the action is to occur

Rationale: Under each statement you must support this nursing intervention with a source as to why it is important

Nurse will perform range of motion every 2 hours.

Rationale: Exercise increases joint flexibility, stability, and range of motion.

Sources: you must have at least 2 sources per care plan. We encourage use of articles and lectures as well. Format in APA.[/TD]

[TD]Goal Met...

Goal partially met...

Goal not met...

This is merely reporting that the goal was accomplished or not.

Goal partially met.

Patient ambulated with assistance of 2 to the chair at 9:30 pm.

***Note that if your goal is met or not met, you need to state what you would expect to find or what you found.[/TD]

[/TR]

[/TABLE]

Nursing Care Plan (continued)

(Correlation Chart)

[TABLE]

[TR]

[TD]ASSESSMENT[/TD]

[TD]ANALYSIS[/TD]

[TD]PLANNING[/TD]

[TD]IMPLEMENTATION[/TD]

[TD]EVALUATION[/TD]

[/TR]

[TR]

[TD][/TD]

[TD]NURSING DIAGNOSIS[/TD]

[TD]GOALS[/TD]

[TD][/TD]

[/TR]

[TR]

[TD][/TD]

[/TR]

[/TABLE]

fitore · Dec 15, 2012

hi Esme12 I really appreciate your help, cos I have started to understand better the nursing process but I have many things that I want to ask, but for now thats all. one of those is : can you explain with other words this sentences cos I can't understand very well the meaning of them:

Support coping process and integration of changes into self-concept.

Start to order a progressive ambulation aids to sit in a balanced position from the procedures to move from bed to a chair to reach equilibrium.

Assess the functional type as the patient does not seem to understand the words or have difficulty speaking / making sense of their own.