My first care plan need help please

dandk1997RN, MSN, RN · Mar 8, 2012

1) It will get easier

2) Use Maslow's hierarchy to determine your priorities

3) Risk for will come after actual diagnoses as far as priority

Your book should give you all the interventions/outcomes you need once you determine your dx.

I can think of at least 5 dx's off the top of my head that would probably work for this patient, the least important of which is probably knowledge deficit or ineffective health maintenance. You can't and shouldn't always try to use the medical diagnosis to figure out the nursing dx. Look at your assessment data- this is the evidence you need to use as the basis for your dx- nothing else really matters.

There was a member here called Daytonite (who has unfortunately passed away) who has left a legacy of GREAT advice on writing care plans. Do some searches and look for her posts for some awesome info on how to succeed with this and how to figure out exactly what you need to look at to come up with accurate, effective care plans.

Good luck!

Esme12, ASN, BSN, RN · Mar 8, 2012

hello,
today was my 1st day of clinical and i've been trying to figure out my care plan for hours, i would appreciate any help on it:
31yr old female presented to the er with abd pain on 2/29
er doc gave a diagnosis her with an ovarian cyst and she saw her ob for ultrasound and
noted a cyst on her right ovary,but stated her didn't think it was related to her she presented to the er once again with vomiting, nausea,fever,night sweats,diarrhea and severe rlq pain. a ct scan showed a periappendiceal abscess, she underwent surgery and a jp drain was inserted yesterday. since my class is in our 1st semester of clinical i have to create a care plan for only today. the only probern is that we have to use the nanda book and her diagnosis in the book at all. i have no clue where to find all the nanda components for her dx. in her chart the pt refuses to use the compression device on her legs and has refused her heparin med today. during her assessment i asked if she was a smoker she said no but her chart states she smokes and refused smoking cessation teaching. one other thing i noticed is that a culture on the jp drainage was done and a phoned in preliminary report was phoned in results were many gram positive cocci in chains and pairs were present. i've tried to research this and can't find out much about it. is it a staph or mrsa infection and how does that happen on the appendix? unfortunately that was later after my clinical was over i went into the chart to get some info i missed so there was no explanation or dr orders were entered yet.
if anyone can give me some advice i would greatly appreciate it, so far i have been stressed out and hope this will get easier with time...
thank you

ok, you have a ton of information here. don't focus on the medical diagnosis. she has had surgery, therefore she is a post op patient right? what does a post op patient need? she has pain from the surgery, right? she has an infection, right? she has knowledge deficits about disease process and post op care right?

so she may have activity intolerance due to what? she may have ineffective airway clearance due to why? smoking hx and poor cough post op? she has pain due to surgery right? impaired skin integrity related to what? surgery and the puncture wound from the jp? she's non compliant due to insufficient knowledge or why...family issues? coping mechanisms, body image?

https://allnurses.com/nursing-student-assistance/nursing-diagnosis-290260.html

ok....first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. let me try to help you. there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) https://allnurses.com/general-nursing...ns-286986.htmlyou can also use the search on this site to lead you to care plans. i have supplied links of examples at the bottom for care plans. think maslows hierachy of needs. maslow's hierarchy of needs - enotes.com virginia henderson's need theory

maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

self-actualization – e.g. morality, creativity, problem solving.
esteem – e.g. confidence, self-esteem, achievement, respect.
belongingness – e.g. love, friendship, intimacy, family.
safety – e.g. security of environment, employment, resources, health, property.
physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis.

assumptions

maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

the needs maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
growth needs are the highest level, which is self-actualization, or the self-fulfillment.
maslow suggested that only two percent of the people in the world achieve self actualization. e.g. abraham lincoln, thomas jefferson, albert einstein, eleanor roosevelt.
self actualized people were reality and problem centered.
they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
they tended to be spontaneous and simple.

application in nursing

maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions. https://allnurses.com/lpn-lvn-nursing/i-need-help-665349.html

https://allnurses.com/general-nursing...ns-286986.html
care plan basics:
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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

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:

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)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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.

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: activity intolerance) is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition).

activity intolerance

(page 3,

nanda-i nursing diagnoses: definitions & classification 2007-2008

)

definition

:

insufficient physiological or psychological energy to endure or complete required or desired daily activities

(does this sound like your patient's problem?)

defining characteristics (symptoms):

abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness

related factors (etiology):

bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle

i've just listed above all the nanda information on the diagnosis of activity intolerance from the taxonomy. only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.

in order to choose nursing diagnoses, you also need to have some sort of nursing diagnosis reference. there is some free information on the internet but it is limited to about 75 of the most commonly used nursing diagnoses. so you will need some sort of reference book. i like this one (i have no affiliation) [h=1]nursing care plans: diagnoses, interventions, and outcomes [paperback] [/h][color=#004b91]meg gulanick (author), [color=#004b91]judith l. myers (author)amazon.com: nursing care plans: diagnoses, interventions, and outcomes (9780323065375): meg gulanick, judith l. myers: books

one more thing . . . care plan reality: nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. they are all linked together with each other to form a nice related circle of cause and effect.

you really shouldn't focus too much time on the nursing diagnoses. most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. the nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.

you may also like these resources

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

understanding the essentials of critical care nursing

nursing care plans, care maps and nursing diagnosis

i hope this helped :) :paw:

Kaysmom8 · Mar 8, 2012

Thank you for your help, I didn't realize that daytonite had passed away. Before I posted this I was reading through some of her posts and I decided to post to ask for help and hoping she would respond When I just read that now I instantly got goosebumps and I'm very sad to hear this as anyone who has read her posts knows she was always willing to help someone out simply an amzing person!!!

I talked to my instructor and was told that since we are only starting our clinicals with 1 day a week for 4hrs for the next couple of weeks, our assessments and care plan will only be based off of our time with the pt for that day. My only problem is my pt was a nurse herself, I wanted to go with pt refused her heparin meds, refused compression devices and she has no appetite and ate very little or her telling me that she didn't want to eat to much because she was unable to exercise? Which one of those should I go with? I have the book the school recommended we use 9th edition of nursing dx handbook by evolve. I initially was going to go with non compliance but the book doesn't reccommend this they prefer Innefective health maintenance be used and what would I say it's related to?. Am I making the wrong choice I really hate to use this one because she has been a nurse for several years and I would hope she knows this can potentially halt her recovery. Is there another one that I may be missing that better fits her seeing that she is in the health care field?

Thank you

grownuprosie · Mar 8, 2012

You are right, she should know better, but nurses can be the worst pts with the worst health maintenance. Just because she is a nurse does not mean these dx do not apply.

nurseprnRN, BSN, RN · Mar 8, 2012

i'm flipping through my nanda 2012-2014 (which is the one you should have) and i can find several, even with the really minimal assessment data you have shared with us. nursing diagnoses are not to be found in some mythological chart with the first column being medical diagnoses and the second giving nursing ones, with the implication that nursing diagnoses are somehow derivative, secondary, or subordinate. nothing could be farther from the truth.

medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

so, you don't think of a diagnosis for your patient and then go searching for supporting data. you collect data and then figure out a nursing diagnosis.

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

so let's see what the nanda index suggests to us. i'm not saying that these nursing diagnoses are the "right" ones for your patient, though from what you tell me, i'll bet that some are pretty likely-- you will have to check them out in the book to see if they fit your assessment data. that said, consider:

risk-prone health behavior

ineffective self-health management

impaired physical mobility

disturbed sleep pattern

hopelessness

risk for compromised human dignity

disturbed body image

disturbed personal identity /risk for disturbed personal identity

interrupted family processes

impaired social interaction

defensive coping

ineffective coping

fear

spiritual distress

risk for injury

delayed surgical recovery

acute pain

impaired comfort

social isolation

look at them and see if some of defining characteristics fit your assessment. then think about what they were caused by, and what a nurse could do about them independent of the medical plan of care. don't feel bad if you can't just do this right off the bat-- it's not like anything you've ever done before, that's why you're in school. use your resources, like the nanda. it will help.

Kaysmom8 · Mar 18, 2012

First of all a big Thank you for all that replied you were such a big help!!!! I got my care plan back and the only mistake I made was putting a few etiologies in the symptoms column. I'm having a little problem with those. Hopefully one day i will be able to return to this board as a rn and help out those who are learning this wonderful yet challenging profession, seriously you guys are the best.... :yeah: :heartbeat

nurseprnRN, BSN, RN · Mar 19, 2012

you're so welcome! glad to help.

"etiology" means "cause." an etiology causes symptoms. symptoms don't cause anything, they are results of problems. does that help?

Kaysmom8 · Mar 19, 2012

I think I got it, rales and diminished lung sounds are the symptoms? My pt's etiology was copd w/exacerbation.

nurseprnRN, BSN, RN · Mar 19, 2012

yes. rales (pronounced "rahhlz") are the sounds of wetness in a chest. you can duplicate it by rubbing some of your hair (or, if yours is very short, some of a close friend) between your thumb and finger next to your ear. rales are a symptom of (usually) congestive heart failure with volume overload.

diminished sounds can be caused by lots of things: poor inspiration (like when a diaphragm can't drop down well due to abdominal distension, weakness, pain, or residual air-trapping), lots of crud (that's a technical term ) clogging up airways, big dense pleural effusion between the lung and your stethoscope diaphragm, or less lung tissue. he might have one or two of those going on, but you have more data on him than i do.