am i writing this diagnosis right? acute pain r/t tissue trauma associated with surgery, evidenced by a patient rating of 7 on a 0-10 pain scale.
yes, this is written correctly. however, unless your instructors want acute pain of a surgery sequenced as a priority, see page 83 in your book, nursing care planning made incredibly easy. pain, to my way of thinking, is a comfort issue and is in last place on the list of physiologic needs.
dear heart, if this patient had surgery, does she have an incision somewhere? if so, then she has impaired tissue integrity
you have a very good care plan book. take a few moments to look at the table of contents page. part i is organized by, surprise! the steps of the nursing process:
- 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)
when i answer care plan questions here on allnurses that is the sequence i keep telling students to follow. those who are having problems are not following this sequence of activity. i can tell in seconds from just reading what they post. the biggest problem students have is assessment. the reason for this is just because you are all inexperienced at it. some abnormal data could be waving and yelling out at you and you will still miss it because it just doesn't seem abnormal at first. this is why you also have to read about the signs and symptoms of the diseases and conditions that patients have in order to help you learn this information. and, as time goes on and with clinical experience you will also pick up on more about assessment.
the other area of problems is nursing diagnosis. many students skip through assessment and go right to diagnosis without realizing the role assessment data plays in determining nursing diagnoses, goals and nursing interventions. probably 90% of the questions on the forums asks what nursing diagnosis to use for a patient with some medical disease. it doesn't work that way. a medical diagnosis is different from a nursing diagnosis.
if you are going to use impaired physical mobility r/t pain and muscle atrophy
then you must have the defining characteristics (patient symptoms) which you found during your assessment as the items following the aeb part of the diagnostic statement as evidence supporting the existence of this problem.
my outline says i have to have 3 dx 2 actual one risk this is one of my actuals, and it says we need all 3 parts, problem statement, etiology (r/t) and signs and symptoms.
see page 63 in the book, nursing care planning made incredibly easy
, which explains what these three parts are. the very first pages of nursing diagnosis handbook: a guide to planning care
by betty j. ackley and gail b. ladwig does a really good job of explaining the construction of the 3-part diagnostic statements.
p - e - s
problem - etiology(ies) - symptoms
these are, in nanda language
nursing diagnosis - related factor(s) - defining characteristic(s)
in a care plan they look like this:
problem [related to]etiology(ies)[as evidenced by]symptom(s)
nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)
the related factor is the underlying cause of the problem or the cause of the signs and symptoms that the patient is having. to help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. to help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". "by taking away this factor, will the symptoms go away?" remember this important rule: you cannot list any medical diagnosis as a related factor. you have to state a medical condition in some other scientific terms. as an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". they essentially mean the same thing--the difference is in the phrasing of the words.
the defining characteristics are always the signs and symptoms that the patient has. these will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to adl evaluations that were not normal.
for your at risk diagnoses, or potential problems, look at the potential complications this patient is in danger of getting. this is a surgical patient, right? what are the potential complications of the specific surgical procedure she had done? is she likely to be at risk for any of them? you may be able to find that information on this website by looking up the procedure (surgery) she had:
also, the complications of general anesthetic are:
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- surgical pain
- nausea/vomiting (paralytic ileus)
and, the complications of epidural anesthesia are:
- rash around the epidural injection site
- nausea and vomiting from the opiates administered
- pruritis of the face and neck caused by some epidural narcotics
- respiratory depression up to 24 hours after the epidural
- cerebrospinal fluid leakage and spinal headache from accidental dural puncture
- sensory problems in the lower extremities
is your patient likely to be at risk for any of those problems (depending on the type on anesthesia she had)? i gave you the lists of anesthetic complications to illustrate how important assessment and critical thinking are as a part of the nursing process in care planning. that first step of the nursing process (assessment) is a doozy, i keep telling students this, but i don't think you all believe me. you can never know too much. you have to be like a detective and always be on the alert for data. you never know what is going to break the case. and, believe me, patients from time to time do drop bombs of shocking information that make all the difference in the world in their care.
i don't think i have the time to start from the beginning and learn all of this stuff inbetween whatever else we are doing. i got my care plan book out but i feel very lost.
use the index in the back of nursing care planning made incredibly easy to find subjects as you need them. this is a very easy to read book and i use the index to find things in it. however, the first part of it is organized according to the steps of the nursing process. as long as you are following the steps in sequence, you should be able to find your way through this book. it will become easier as you get more experience writing care plans.
if you are still having trouble, ask for help.