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 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.
what care does the patient need? are they early or late stage? are they safe? what is their mentation? are they at risk for falls? have they fallen? are they able to swallow? can they care for them self/perform adls? what is their cognitive status? are they incontinent? is their skin intact? can they speak clearly? are there contractures present?
you may find this site helpful....
nursing approaches to care in hd