you are making the same mistake many nursing students make and using the medical diagnosis to fit the patient into the "nursing diagnosis" you have chosen.
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. you need to know the pathophysiology of your disease process. you need to assess your patient, collect data then find a diagnosis. let the patient data drive the diagnosis. what is your assessment? what does the patient say? what are the labs? what does the patient need? what is the most important to them now?
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.
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 them as a recipe to caring for your patient. your plan of how you are going to care for them.
from a very wise an contributor daytonite.......
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
- 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)
a dear an contributor daytonite always had the best advice.......check out this link.
you need a good care plan book. i prefer gulanick: nursing care plans, 7th edition. they have an online care plan constructor. it used to be free but they caught on so now you need to buy the book to use the constructor.
care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and try to fit the patient into diagnosis.
"nursing diagnosis is: excess fluid volume r/t impaired excretion of sodium and water as exhibited by elevated vital signs of temp of 98.6°f, rr of 24, and bp of 188/90, pt's wt gain of 6lbs within four days, crackles in posterior bilateral lower bases, and slightly pitting +2 edema secondary to congested heart failure."
ok .....excess fluid volume related to decreased cardiac outout secondary to chf aeb rr rate of 24, pt's weight gain of 61 labs, pitting edema and an o2 sat of.........
what is the nanda taxonomy? what is the patients assessment? what is their complaint? do you have a care plan book?
decreased cardiac output r/t what? cardiomyopathy? cardiomegaly? cad? aeb your assessment (for example: he has the history of chf, he has an s3 present, tachycardia, htn, low spo2 (92%). he is sob)
ok you know that he has chf. what is chf? i know congestive heart failure..... but what exactly chf. does this patient have right or left heart failure? is this patients chf from a weakened heart muscle from previous mi's or some form of cardiomyopathy caused by long with standing htn and diabetes or valvular disease? you need to know this before determining if this is what is causing his decreased cardiac output.
waht are this patients co-morbidities? what els edoe this patient need.
let me google that for you
i use this to remind people anyone can google but i use it as an engine too.....
congestive heart failure prognosis, symptoms, stages, causes, treatment - emedicinehealth
requires registration but it is free and a great resource.
i helped some one else on a chf care plan and there are good ideas and information
some other helpful links........
nursing care plan | nursing crib
nursing care plan
nursing resources - care plans
nursing care plans, care maps and nursing diagnosis
understanding the essentials of critical care nursing