Nursing care plan

Episteme · May 21, 2014

I have to do case studies such as this:
1. Mr. A. was admitted to a long term care facility several days ago. A nursing student is assigned to care for him. Upon assessment, the nursing student finds that Mr. A is quiet and withdrawn and becomes tearful at times. He is curled in a fetal position. His extremities are stiff when the student attempts to move or reposition him. He groans and cries when moved.
Need:
Assessment
Nursing diagnosis (3 of them)
Nursing interventions (3 for each diagnosis with rationale)
Short term goals (3 of them)
Long term goals (3 of them)

He is "quiet and withdrawn". Does he speak at all or is he totally non-verbal and if so for how long? He's a little old guy curled in a fetal position and his limbs are stiff. Is his movement gegenhalten? Or is he contractured. He groans when moved. Do we have any information about possible sources of pain?

I'm sorry. I think you are being taught that you are supposed to intuit nursing diagnoses with almost no information, and come up with outcomes, without establishing what his current baseline is. Frankly, this vignette tells us nothing.

On p.77 of NANDA-I book Nursing Diagnosis definitions and classifications I read...

The diagnostic reasoning associated with nursing assessment involves recognizing the existence of cues, mentally generating possible diagnses, comparing cues to possible diagnoses, conducting a focused data collection and validating diagnoses."

Can you honestly say the information you have meets those criteria? FOCUSED DATA COLLECTION???!!!

Really? old man, fetal position, groan, stiff, tearful. That's it? Could be an old stroke patient with global aphasia who has an acute abdomen. Could be an old guy with end-stage dementia. If I don't have further information, and I plan care for the demented man, but he in fact is the aphasic with a hot belly... I've killed him.

I would appreciate someone telling me I'm wrong... but I think this is nonsense.

nurseprnRN, BSN, RN · May 21, 2014

You don't ask us for "assessment." YOU do the assessment. That includes reading his chart and talking to his family or other caregivers if you can. You are not responsible for making the medical diagnosis of CVA, dementia, acute abdomen, or whatever. If nobody knows what his medical diagnoses are, that doesn't matter to you right now. Really. Because this is a nursing assignment, not a medical student assignment. You can't think that nobody gets nursing care until and unless he has a medical diagnosis, right? It really doesn't work like that.

The quote my friend Episteme gives above about what to do can be translated into easier English. It means,

* You make observations to see if you can see behaviors or other data that give you clues to what's going on c him from a nursing needs standpoint

* Then you make a guess(es) about possible nursing diagnosis(es)

* Then you read the nursing diagnoses to see if what you observed matches the defining characteristics for any of them

* Then you assess more carefully using hints from the list of defining characteristics for what to look for

* THEN you you have the evidence to validate your guess(es) about the nursing diagnosis(es), (or search for different ones), and you make them.

And only then can you plan what care you need to give this patient (or delegate to someone else to give).

Make diagnosis first, plan care second, whether you are a physician, nurse, physical therapist, psychologist ...

Episteme · May 21, 2014

GrnTea: For sure, I'm not saying my nursing diagnosis would be dementia or diverticulitis with sepsis... See... if I were really there... I'd instantly have more data. I would see someone with a fever and tachypnea, or not. Most importantly in this case study... the minute I reach the bedside... I'm going to assess if this patient is looking at me... does he track me with his eyes. I would almost instantly know if this guy has any focal deficits. And yes... give me some data (because I'm not there) and I can discern the cues, postulate a nursing diagnosis, and then go on a thorough (pretend, theoretical) hunt for my defining characteristics. (I used pathophys/medical-ish terms in my post as a linguistic short-cut. it might confuse the student... I hope not :unsure:

I think what I see as foolish is the very, very skimpy assessment data and expectation that the student should intuit three diagnoses out of the ozone. As an educator, here is how I would use this so-called "case study".

"Alright students...you've only just stepped in the room and made these few assessments. Your assignment is to think of possible domains from which you'll be drawing your diagnoses, and tell me why you are going there. Your second assignment is to list the assessments on which you'll focus to find your defining characteristics.

Then, GrnTea, I would have a robust discussion with the students and when everyone had come up with their list, I would say, "Now Betty. You've heard Mary's list of diagnoses. Which one do you think should be her priority diagnosis and explain why you picked that one."

I mean, do we really want students to think they can do this on a patient with almost no information? If the faculty honestly want students to do that, I feel like they are trivializing nursing diagnosis. And pedagogically, it's lazy. (Not that I'm strongly opinionated or anything.)

Done the way I suggest... students could learn how and what to assess, and the mechanics (steps) of coming up with the diagnoses.

As you know... I'm coming to this late in life, so tell me if I'm mistaken. (I trust you to be kind...)

nurseprnRN, BSN, RN · May 22, 2014

GrnTea: For sure, I'm not saying my nursing diagnosis would be dementia or diverticulitis with sepsis... See... if I were really there... I'd instantly have more data. I would see someone with a fever and tachypnea, or not. Most importantly in this case study... the minute I reach the bedside... I'm going to assess if this patient is looking at me... does he track me with his eyes. I would almost instantly know if this guy has any focal deficits. And yes... give me some data (because I'm not there) and I can discern the cues, postulate a nursing diagnosis, and then go on a thorough (pretend, theoretical) hunt for my defining characteristics. (I used pathophys/medical-ish terms in my post as a linguistic short-cut. it might confuse the student... I hope not
I think what I see as foolish is the very, very skimpy assessment data and expectation that the student should intuit three diagnoses out of the ozone. As an educator, here is how I would use this so-called "case study".
"Alright students...you've only just stepped in the room and made these few assessments. Your assignment is to think of possible domains from which you'll be drawing your diagnoses, and tell me why you are going there. Your second assignment is to list the assessments on which you'll focus to find your defining characteristics.
Then, GrnTea, I would have a robust discussion with the students and when everyone had come up with their list, I would say, "Now Betty. You've heard Mary's list of diagnoses. Which one do you think should be her priority diagnosis and explain why you picked that one."
I mean, do we really want students to think they can do this on a patient with almost no information? If the faculty honestly want students to do that, I feel like they are trivializing nursing diagnosis. And pedagogically, it's lazy. (Not that I'm strongly opinionated or anything.)
Done the way I suggest... students could learn how and what to assess, and the mechanics (steps) of coming up with the diagnoses.
As you know... I'm coming to this late in life, so tell me if I'm mistaken. (I trust you to be kind...)

I know, but you are more experienced than a student and they might think that they were responsible for thinking the way you do in terms of what we old folks know about medical diagnoses and the reasonable assumptions of what a nurse would do about them.

You and I don't disagree here at all-- I was trying to explain to the student that her assessment was lacking and reassuring her that she didn't have to figure out a medical diagnosis too, or even know what it was, necessarily, to do a nursing assessment and plan. Sorry I didn't do that clearly enough. :)

2016New · May 23, 2014

No. this is not a real patient. Its just an exercise for us to do.

2016New · May 23, 2014

thats exactly what i was thinking! most of the case studies that were given to us had almost no information we could use to come up with very well defined nursing diagnosis…thats whats stressing me out! all of the case studies are very vague.

Episteme · May 23, 2014

You know what? Maybe the vagueness could be a blessing. I think you should get the NANDA-I Nursing Diagnosis Definitions and Classifications. Honest to Pete, that vague scenario gives you a chance to imagine all the possibilities. On the back of the front cover, all the nursing diagnostic "foci" are listed with THE PAGE NUMBERS!!! You can find the official diagnosis on that page and defining characteristics for it. Here's how the vagueness might help you WOW your instructor. Take "communication"

You could say to your professor "the case study says my patient doesn't talk. Therefore I might diagnose him with Impaired Verbal Communication if I found some of these defining characteristics... absence of eye contact, cannot speak, attempts to speak but inability to express thoughts verbally (e.g. aphasia, dysphasia, apraxia, dyslexia) etc. etc."

He doesn't move. Run your finger down the back of the front cover and find "mobility". Go to page 223 and let 'er rip. The book is golden, I swear. Don't let the vagueness of these case studies limit you. Open them up with your imagination and show from this reference (the NANDA-I book) the range of diagnoses that might be possible.

PS: (be sure to cite the reference or rephrase it in your own words.)

thehumbleRN · May 27, 2014

I just grad in Jan...I always loved nursing dx..they are like a puzzle...Think to yourself while you are in clinicals, what is being done for the pt now, today, during the nursing shift??? For ex, in ICU I had a pt on an insulin drip so this was the focus. Do they have a temp? It's whatever the priority of the pt is and from there you pick your dx that fits.

nurseprnRN, BSN, RN · May 27, 2014

You don't PICK a nursing diagnosis. Does a physician "pick" a diagnosis of anemia when the hct is low? No, of course not. S/he makes the diagnosis based on established criteria. Nurses make nursing diagnoses too, based on established criteria. You'll learn.