This is my very first Care Plan, for Maternity. Please help?

  1. OK, so I'm doing my first ever Nursing Process Report (NPR), or a care plan. I was on a postpartum unit, and my patient was mostly just fine, only that she had spiked a temperature of 101.1 F after a vaginal birth. Her temperatures were fine during L&D, and they were also quite normal when I had cared for her. Nonetheless, she was on IV antibiotics. The very morning I had cared for her, one of the doctors' notes gave her a diagnosis of 'chorioaminionitis', which I suppose was giver after her high temp. had come and gone.

    So anyway, I was sorta-kinda able to formulate a nursing diagnosis out of that.

    I put: "High risk for infection r/t chorioaminonitis".

    Am I at least on the right track?

    One other question!
    My syllabus says this: "You are required to have at least one current journal article that you used as a reference for evidence-based practice in developing your NPR."

    Where would I find such a journal article, and in what part of the care plan would I use that journal article for?
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  3. by   Matka
    We can't use a medical diagnosis as our related to statement. I would look at that part again.
  4. by   katiebry1031
    i agree you cant use a medical dx for a r/t. you might be able to say risk for infection r/t fever or something along those lines. but theres a million dx you can use just for postpartum itself. there does not have to be a medical dx to formulate a nursing dx. for example you could use acute pain, knowledge deficit, risk for injury, Ineffective Coping (Depending on the situation) these are just a few.
  5. by   rnmalex
    You could say "risk for infection r/t complications secondary to chorioamnionitis" or something along those lines. But yes, a medical diagnosis is never directly your "related to" section. Different diagnosis books may propose it differently.

    Also, your college library may have access to peer-reviewed nursing journals online.
  6. by   nurseprnRN
    On the contrary, you can certainly use a medical diagnosis as a defining characteristic. When you go to the NANDA-I website it will tell you that you can't use a medical diagnosis as a prompt for the nursing diagnosis-- they specifically say that students often ask "What's the nursing diagnosis for myocardial infarction? (for example)" and there is no answer to that question. However, when you look at the NANDA-I 2012-2014, which is THE definitive book on nursing diagnosis and which all students should have (you can get free 2-day delivery from Amazon), you will find many, many of the nursing dx have medical dx as defining characteristics.

    It's said "Nursing diagnosis A related to X, as evidenced by Y." This nursing diagnosis statement means, "I think my patient has/or might get A, because of X, and I think that X is correct because I have observed/learned in her chart/measured these specific data points Y."

    That said, saying, "My patient is at risk for infection because she has an infection" makes no sense at all.

    NANDA-I 2012-2014 list:

    There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it.

    Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

    For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

    Medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. This is not to say that nursing diagnosis doesn't use the same information; we do. There's no rule that says it's an either/or choice, med school or nursing school, to limit your use of data.

    Nursing diagnoses are derived from nursing assessments, not medical ones. So to make a nursing diagnosis, a nursing assessment has to occur. For THAT, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

    That's why we can't give you an answer-- there isn't one. Also, we don't give you an answer because we don't do your homework for you to copy off the list and hand in. SO.... What do YOU think, based on your assessment of this patient, and why do you think so?
    Last edit by nurseprnRN on Sep 24, '12