Need help writing care plan

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    ANYONE USING SIM CHART??
    I'm doing a patient with COPD, has SOB and Increase Respiratory Rate and increase heart rate. I'm wonder do I have to write my diagnosis as a respiratory and COPD. Then I have to write the pahophysiology about it and Therapeutic Regimen.

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  2. 8 Comments...

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    Impaired gas exchange secondary to bronchoconstriction. Resulting in decreased perfusion, increased anxiety and fatigue. Therapy would include brochodilators to open airways, corticosteroids to decrease inflammation, Ativan to decrease anxiety and tachypnea. Oxygen therapy to maintain sats at 90-95%. coughing and deep breathing. Incentive spirometry. Keeping the HOB elevated. Rest.
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    Quote from BrandonLPN
    Impaired gas exchange secondary to bronchoconstriction. Resulting in decreased perfusion, increased anxiety and fatigue. Therapy would include brochodilators to open airways, corticosteroids to decrease inflammation, Ativan to decrease anxiety and tachypnea. Oxygen therapy to maintain sats at 90-95%. coughing and deep breathing. Incentive spirometry. Keeping the HOB elevated. Rest.
    Alas, all those meds (including oxygen) are not nursing interventions, although nurses are legally obligated to implement some parts of a medical plan of care. Any time you find yourself writing "medications/IVs as ordered" in a nursing care plan you are not writing nursing care, you are restating a medical plan of care.

    OP, there are several threads on nursing care planning going on right now-- reading them will help you figure out how to make nursing diagnoses and support them. Then, and only then, can you start to think about what nursing, independent of medicine, will do for the patient based on the nursing assessment. That is the point of your assignment.

    How about you check some of them out and then come ask the RNs here about what you found out and decided for your nursing plan of care?
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    We just started doing concept maps, and we were instructed to use meds as interventions.

    Everyone I spoke to after the lecture was really confused; how is medication a nursing intervention? Since then , I've discovered that means meds are ALWAYS the priority intervention.

    Very strange since we never used meds on our care plans, other than just to list them as given.
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    Interesting. I never knew that. So if the doctor writes an order stating incentive spirometry and to keep HOB elevated so and so degrees, would that be considered just a rewrite of the medical plan of care? Some doctors really go to town and write a bunch of what would be considered nursing interventions in their orders. I guess what I'm asking is does something being a doctor's order automatically disqualify it from being part of the nursing plan of care? I've always thought that the administration of medicine *was* a nursing intervention, in as much as it's the nurse, not the doctor, giving the meds.
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    There's a decided difference between implementing parts of the medical plan of care being things that nurses do, and developing and implementing a nursing plan of care based on nursing assessment.

    There are overlaps-- raising the head of the bed for dyspnea and teaching deep breathing techniques with IS are not either-or things. You often see physician write things that you would do anyway, because nurses can and do implement those things on our own education and experience, right? You wouldn't refuse to elevate the head of the bed for dyspnea if a physician didn't tell you to, would you (absent other factors, which I trust you would be able to assess)?

    Giving vancomycin or IV fluid rates are not some of those.

    Another way around that is to include assessing the effectiveness of part of the medical plan of care by looking at the improvements/changes in the defining characteristics of your nursing diagnoses.

    In nursing school, and in NCLEX, they want to find out what you know about nursing. If you get an NCLEX question that gives you a patient with symptoms of fluid volume excess and then give you an answer choice of, oh, furosemide (Lasix) 20mg IV, you'd better not choose that. If it doesn't say somewhere that there is a prn order for it with these parameters, and those are not met in the stem of the test item, this is not a nursing intervention. NCLEX wants to know what nurses would do, not physicians.

    I know this is hard for students to get their arms around when every image you ever see of nursing in the press and other media makes it crystal clear that nursing is subordinate to medical plans of care and medical diagnoses. But this is not true, and nursing schools ought not to be reinforcing it to the detriment of respect for nursing per se.
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    Ok, I see the difference more clearly now. Thank you.
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    Any time Glad to help.
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    Quote from Wright88
    ANYONE USING SIM CHART??
    I'm doing a patient with COPD, has SOB and Increase Respiratory Rate and increase heart rate. I'm wonder do I have to write my diagnosis as a respiratory and COPD. Then I have to write the pathophysiology about it and Therapeutic Regimen.
    Welcome to AN! The largest online nursing community!

    We are happy to help with homework but we will not do it for you.......we will lead you to the best way for you to answer it yourself.

    Care plans/care maps are all about the assessment.....of the patient. The is not enough information here for us to help. Tell me about your patient, What is your assessment? What do they NEED? What is their main complaint? What are their co-morbidities? How old is this patient? What is their base line? What meds are they on?

    YOU MUST have a good care plan book with the NANDA diagnosis and it defining characteristics.

    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. From what you posted I do not have the information necessary to make a nursing diagnosis.

    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.

    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

    1. 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)
    2. 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)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. 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 is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    So tell me about your patient
    .......What do they need? What do they c/o? ? What is your assessment......What does this tell me about the patient?
    martha keaton likes this.


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