Is this allowed on a care plan?

  1. I am doing a patient care plan on asthma. I am using the "Ineffective breathing pattern" for my diagnosis. I was wondering, if in the 'related to' statement, if I am allowed to state "related to diagnosis of asthma," or if I am not allowed to explicitly state the medical diagnosis as such.

    Any help is appreciated!
    Thank you
  2. Visit santina44 profile page

    About santina44

    Joined: Jun '10; Posts: 26; Likes: 2


  3. by   RNTutor
    Hmm, actually, I think I have seen it done both ways. Personally, I try to stay away from using the medical dx in the nursing dx, but I'm not going to lie and say I never do it for something like this. I would check with your instructor and see what they like to do.

    But some other ideas besides using "asthma" are to describe the underlying physiology of asthma, such as r/t airway inflammation and increased mucus production.

    I'm interested to hear other nurses' comments too...
  4. by   santina44
    Thank you for our reply! I asked my professor and she said to not use the medical diagnosis unless you write something as follows:
    "Ineffective breathing pattern r/t to bronchial constriction secondary to asthma."
  5. by   Armygirl7
    We aren't allowed to use the medical diagnosis either unless as a "secondary" like your instructor said.

    And it's been good to start thinking like that because it helps me know what to do next as a nurse when I am properly focused on treating the effects of the disorder, the human response to the problem, and not focused on the typical pathology of any given disease or diagnosis.

    Man, those care plans can rally stump you sometimes! I find them aggravating at times but I do see the value in breaking it all down like that, for sure.

    good luck!
  6. by   RNTutor
    Absolutely! And thanks, santina44, for letting me know what the final ruling was from the instructor. That was very good information, and a better way for me to think about writing nursing dx in the future!

    Armygirl7: I am so glad you understand the point of care plans!! There are so many students who complain about them, but I think it's often because they don't understand the purpose. And the purpose is exactly what you focus on treating the effects of the disorder and the human response, not just the disease itself. That's the doctor's job! But the process of breaking it down into a care plan definitely helps develop your "nurse problem-solving" brain muscle.
    Last edit by RNTutor on Jun 6, '10