I need HELP UNDERSTANDING CARE PLANS PLEASE!!!

[nette1022]

I am a new student, this is my first care plan, I don't understand how to put it together. I know the more I do them the more I will understand them, but when you are new it's like learning a foreign language. Can someone please have mercy on me? If I could get an example of how this should look I would really appreciate it.

Here is the scenario:

Romel Jones is an 11-month-old infant who was seen this week at the developmental pediatrician's office and was diagnosed with spastic cerebral palsy. He was referred by the pediatrician's office because he is not rolling or attempting to sit. He has hypertonia of the lower extremities. Romel is the fourth child of a 26-year-old single mother, who developed preeclampsia. He was born at 24 weeks gestation with a birth weight of 1 pound 4 ounces, and spent 3 months in the neonatal ICU, where his treatment included mechanical ventilation and tube feedings. When he was discharged home 8 months ago, he was on an apnea monitor, receiving bronchodilator medication via nebulizer, and was taking bottle feedings. His weight gain has been slow but steady, and currently he weighs 15 pounds and is 26 ½ inches long. Romel is seen monthly by a public health nurse, who has been assessing his health status and development, and teaching his mother about using a nebulizer. Romel's mother is very upset at hearing his diagnosis. She states she knew they were going to follow him for possible developmental problems, but that she had not heard anything about cerebral palsy before.

I have a nursing diagnosis of Risk for ineffective parenting but the related to and all that I am confused. Once I see it I can comprehend it. All my instructor does is tell me where I am wrong. She is not explaining to me how this should be done, this is why I am a student I am trying to LEARN. PLEASE HELP ME. I REALLY WANT TO BE GOOD AT THIS, THIS IS THE BASIS OF NURSING (WELL ONE OF THEM ANYWAY).

THANKS in advance

[Esme12, ASN, BSN, RN]

[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]

[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
  

[/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]

[nette1022]

Now the diagnosis makes sense. Is my goal and outcome right? You have been an immense source of info thanks. I am printing this stuff out now.

[nette1022]

I went to the webpage for care plans, it's saying wrong address.

[nette1022]

It's okay I did a search and found it, THANKS. It's wonderful to have a nurse take time to help someone that's trying to learn, I appreciate you taking the time to really help me.

[Esme12, ASN, BSN, RN]

I use firefox here ......you are very welcome...anytime I will check your goal and out come in a bit I have to get dinner on the table....LOL

[Carpediem1012, BSN, RN]

Thank you both so much for creating this post. What a great resource!

[SageFemmeReveur]

I'm still a year away from applying to nursing school but I am printing this out and putting it in a file I've started for (hopefully!) when I start nursing school. Esme, I've read several of your responses in different areas on the site and I just have to say you are such a sweetheart, so darn helpful, so wise and intelligent.

[NRSKarenRN, BSN, RN]

I see you've found our Nursing Student Assistance forum. Click on the FREQUENTLY ASKED QUESTION link at top of section to see all the stickied posts on major student topics.

Thread Can anyone help on care plan? has much advice

[bagface]

Esme as a student I love coming to the boards and seeing what you post, I love how you encourage and help other students by guiding them so they can gain the necessary critical thinking skills they need.. I hope your students in real life know how lucky they are to have someone so dedicated and patient to their learning.

[nurseprnRN, BSN, RN]

I am using Mosby's nursing diagnosis book. I understand what you are saying.(I think). So my nursing diagnosis should be Delayed Growth and Development related to being diagnosed with spastic cerebral palsy born at 24 weeks gestation with a birth weight of 1 pound 4 ounces. A measurable patient outcome would be: Achieve realistic developmental/and or growth milestones based on existing abilities, extent of disability, and functional age. Criteria to establish this outcome has been met is: provide parents/and or caregivers realistic expectations for attainment of growth and development milestones. Clarify expectations and correct misconceptions. Is this correct so far? Thank you for taking the time to help me, I really, really, really appreciate it.

OK, this is long, but this is important enough for you to get it early on. And I have just the references you want.

You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle or iPad at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this. In your case, the diagnosis of delayed growth and development is not caused by being diagnosed.

If you go to page 484 in the NANDA-I 2012-2014, you will see the defining characteristics for the nursing diagnosis of "Delayed growth and development." They are:

* Altered physical growth

* decreased response time

*delay in performing skills typical of age group

*difficulty in performing skills typical of age group

*flat affect

*inability to perform self-care activities appropriate for age

*inability to perform self-control activities appropriate for age

*listlessness

If you identify at least one of those in your assessment, which includes whatever you find the chart, then that's your defining characteristic. You might find more than one.

The related factors for Delayed growth and development are:

*effects of physical disability (specify)

*environmental deficiencies

*inadequate caretaking

*inconsistent responsiveness

*indifference

*multiple caretakers

*prescribes dependence

*separation from significant others

*stimulation deficiencies

If you identify at least one of these in your assessment, then you have your related factor.

Therefore, your nursing diagnosis will probably look something like this:

Delayed growth and development related to the effects of physical disability (cerebral palsy with hypertonia of the lower extremities), as evidenced by delay in performing skills typical of age group (inability to roll over or attempt to sit) {or whatever else you decide gives you the data to make your diagnosis}. Does that make sense?

Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. It would probably have something to do with no increase in pain due to decreased circulation, or perhaps no increase in tissue injury, you might also consider some of the educational components, so one of your outcomes might be that the patient describes…, so you understand that he knows more about his disease.

I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 209-220 you will find major, suggested, and optional interventions for the Growth and Development nursing diagnoses. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. You get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them. It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.