developing a care plan involves applying the nursing process because what you are doing is ferreting out their nursing problems. the nursing process helps you do that in an organized way. you can see how this works because i have many posts on the help with care plans
) where i show how to do this as well as a hundred or more posts scattered throughout this and the nursing assistant discussions forum where i have also demonstrated it.
step #1 - assessment
- consists of collecting as much initial data about the patient as you can get. assessment includes:
step #2 - determining the nursing problems (nursing diagnoses)
- a health history (review of systems) - this is a 3-year old male with cerebral palsy who is in long term care and has brain trauma as a result physical abuse.
- performing a physical exam - no physical exam information is provided. what are the behavioral tasks for a normal 3-year old and what is this child actually able to perform? what growth and development deficits does he have? if you are in peds your instructors will be looking for this component in your care plan with links to erickson's stage of development and developmental milestones.
- see the pediatric weblinks on this thread to find several weblinks that have pediatric milestones on them: http://allnurses.com/nursing-student-assistance/medical-disease-information-258109.html - medical disease information/treatment/procedures/test reference websites
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - only information provided is that he sits in a w/c and can't talk. how does he get to the chair? what about his other adls? at 3-years old someone bathes, dresses, helps him toilet (is he incontinent?) and dress him. these are self-care deficits.
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition you need to look up the signs, symptoms and pathophysiology of cerebral palsy because some of that information is needed for the related factors (r/t part) of your nursing diagnostic statements. these websites will have the pathophysiology and signs and symptoms of cerebral palsy:
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - none mentioned. some drugs the patient is getting are clues to medical problems that are also of interest to focus on.
- from all the data you have collected above you sort out the stuff that isn't normal. we already know that sitting in a chair and being nonverbal isn't normal. but not being able to care for himself also isn't considered normal in the nursing world because nurses are caregivers and we promote independence. children need assistance with their care anyway. there is a great deal that was missed regarding his care. think back to what his current caregivers do for him and the reason behind them all and you will have some of the symptoms you missed. the nursing diagnosis itself is merely a name we put on the actual problem.
step #3 - planning
- impaired physical mobility
- self-care deficits (there are 4 specific ones)
- impaired verbal communication
- delayed growth and development
- this is the time you write the goals and nursing interventions for the problems based upon the evidence that proves each problem.
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1. inability to communicate r/t _____ secondary to dysphagia aeb______.
2 impaired mobility r/t ______ secondary to brain trauma aeb_______.
- this is not a priority diagnosis and should not be sequenced first.
- "inability to communicate" is not a nanda approved diagnosis. the correct name is impaired verbal communication.
- nanda diagnosis lists and taxonomy can be found here:
- your r/t (related factor) is always the etiology, or reason for the problem. in this case it can be attributed to his medical condition--the brain damage + the cerebral palsy, but it cannot be stated as the medical condition. it must be stated more generically, such as "r/t neurological impairment secondary to physical trauma and cerebral palsy"
- be careful of the terms you use and your spelling. "dysphagia" is difficulty swallowing. even if you used dysphasia (impaired speech) which is probably what you meant it would be a wrong etiology because you are merely restating the problem and not telling us what the cause of the impaired speech is.
- where is your evidence? what follows the aeb part of the statement is the evidence you have of the problem. all you said was that he can't talk. that's evidence. does he make any gestures, grunts etc.? you should always have evidence first before choosing a diagnosis.
3. any ideas on a third one?
- this should have been your first listed diagnosis.
- "impaired mobility" is not a nanda approved diagnosis. the correct name is impaired physical mobility.
- as i said above, the r/t (related factor) is always the etiology, or reason for the problem. in this case it can be attributed to his cerebral palsy. that is "neurological impairment secondary to cerebral palsy".
- what evidence do you have of this problem other than he is confined to a w/c? what can't he move? you have to describe and write these things down.
- see above. you have to do a more thorough assessment and you will get a better idea of what is going on. i am sure there are many other problems that you are just not seeing yet because of inexperience with assessment.
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the construction of the 3-part diagnostic statement follows this format:
p (problem) - e (etiology) - s (symptoms)
- problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
- etiology- also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
- symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.