a care plan book or disease cross reference to nursing diagnoses is only giving you suggestions for nursing diagnoses. these suggestions might tweak your thinking, but it is still up to the nurse to determine what nursing problems you have to deal with in the first place with this patient and no book is going to be able to tell you that. this is why it is useful to use the steps, no, essential to use the steps of the nursing process when care planning. steps #1 and #2 in that order are critical (as in critical thinking). a care plan is all about solving a patient's nursing problems.
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)
assessing is the most crucial activity. it will take you years to perfect this skill. for the time being you have to work with the information you gathered and some that you can add now. assessment includes:
- a physical assessment of the patient
- assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
- data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
- knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
this patient has the following medical diagnoses/conditions
- lower gi bleed
- s/p transverse colectomy
- type ii diabetes
- recent cva
every one of these conditions has signs and symptoms of varying subtleties depending on how severe a case the patient has. those signs and symptoms contribute to this patient's nursing problems, so you need to list them out. you already know several of the signs/symptoms:
- hemoccult + stools
- low hgb & hct
the heme-positive stools and low h&h are strong evidence of the gi bleed. what medications is the patient on? some medications can alter the hemoccult tests. how recently was the patient's surgery? is the incision healed? for what medical reason was the colectomy done? removal of 1/3 of the colon alters the formation of stools leaving many patients with diarrhea--did you ask about this? is it possible that this gi bleeding is a complication of the surgery? or, is the doctor looking for cancer or some other gi pathology? what did the physician's h&p and progress notes say? diabetes is a chronic condition that comes with long-term problems and complications that form subtly over time. surely, blood sugars were being monitored. strokes are often attributed as being complications of diabetes because of the underlying atherosclerosis going on in diabetes. strokes also leave patients with some degree of self-care deficits. so, the patient's ability to perform adls should have been assessed. the neurological deficits left by the stroke may be subtle, but they will be there and they will affect the way the patient carries out and conducts their daily routines. nursing interventions may simply involve suggestions on how to do things a different way the patient hadn't thought of.
if is important that you look up the signs and symptoms of diabetes and cva in order to double check that you didn't accidentally miss seeing one or more of them in this patient.
you also should look at the medications that were prescribed for the patient and why they are being given to try to understand what the doctor was treating.
this is all information that contributes to your assessment of the patient's situation. you are, in essence, being a detective trying to collect as much evidence
as you can. in fact, some of this evidence later will end up supporting the nursing diagnoses you choose (as in your nursing diagnostic statements where you have a nursing diagnosis related to an etiology as evidenced by
the symptoms which are listed next).
the 2nd step in the care planning process (all the above was step #1 - assessment
) is to diagnose based on your evidence. you list out all the abnormal data (evidence). it is easier to call it signs and symptoms, but in the nursing world and the world of care plans
and nanda it is called defining characteristics.
it is at this point where you need to have a nursing diagnosis reference. every nursing diagnosis has a list of defining characteristics all its own. a nursing diagnosis is only a shortened phrasing of the true nursing problem. the much more defined explanation of the problem is contained in the definition of the diagnosis and you should read these definitions every time you use a nursing diagnosis so you get a good understanding of what each diagnosis is really about. there are a number of ways to find this nursing diagnosis information:
- your instructors might have given it to you.
- you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
as you may have already found if you have a book of care plans, a care plan for gi bleeding may or may not be listed in it. care plan books only have care plans for the most commonly seen medical diseases. the problem, however, is that there are plenty of reasons that people are needing nursing care that don't involve a commonly seen medical disease and this is why you need to know how to formulate care by way of using the nursing process. make sense? this nursing process, or problem solving method, can also help you fathom out the answers/solutions to all kinds of puzzles and not just care planning. so it is a handy tool to have and use.
there are also sticky threads on care planning:
if you are still having problems coming up with nursing diagnoses go back through your assessment based on the directions for assessing that i just gave you. if you still can't figure diagnoses out, list the abnormal data and we'll see what we can come up with. keep this in mind. . .this patient wouldn't be hospitalized if there wasn't a need for 24-hour nursing care. assessment, teaching and management. if it takes backing into the care plan from that point of view then that is another approach to take in reasoning this care plan out.