Another Care Plan Question

NurseyBaby'05, BSN, RN · Sep 28, 2006

What about an actual diagnosis and a "Risk for" diagnosis? Risk for self-injury comes immediately to mind. Self-esteem, chronic low for current. It seems to me that any diagnosis appropriate for a current situation can me made a "Risk for" for the future depending on the patient's individual situation.

e.g. He's depressed. Is he fatigued? How is his appetite? How is his hygeine? If he's eating ok now, that could change. As his illness progresses, he may not be able to take care of himself as well. Hygeine could come into play. Then again, maybe his hygeine and appetite have already taken a nosedive, so those diagnoses would be current.

Does this provide any clarification or does it muddy things up further? I've been known to do both.

Daytonite, BSN, RN · Sep 28, 2006

hi, michelle123!

i think that what your instructor was talking about was the data collection part of the care plan, or nursing process. when you are doing care plans on imaginary patients (i'm assuming that "aaron" is not a real patient, but a patient from a case scenario), or even a real patient, things like a review of the medication the patient is taking becomes valuable data that you need to add to your assessment. you cannot begin to start to choose nursing diagnoses for a patient until you have done as thorough a data assessment as you can do. remember the practical application of the steps in the nursing (written care plan) process is:

assessment
nursing diagnosis
planning
implementation
evaluation

there is a lot involved in the assessment process. assessment involves reviewing as much information as you can about the patient as well as performing your own interview and physical assessment. if you were seeing "aaron" in the hospital you would scrutinize the information that was available in his chart, including the medications that were ordered for him. ask yourself why is he on this medication? does it match with the known list of medical diagnoses that you do know about? if not, a question to ask the patient will be, "why are you taking this medication?" since it might reveal something about "aaron" that wasn't in his written record.

from all these data items that you collect, you make a "shopping list" of all the non-normal ones. this list is the basis that forms the groundwork of the "related to" symptoms of the nursing diagnoses you are going to eventually chose in step #2 of the care planning process. just as each medical diagnosis has symptoms that define it, the same is also true of nursing diagnoses. at this point in the process a nursing diagnosis handbook can be a great help to you, particularly if it has an index that cross-references symptoms and lists nursing diagnoses that might apply to your patient. it will help point you to diagnoses that could apply to your patient's situation(s).

in your particular case, you have already provided me with one clue about the patient. he has depression. now, if this were an imaginary patient, and this were the only information i was given and told to write a care plan about him, i would go to a book of pathophysiology, or more likely, to one of several websites i use and look up this particular disease and find a listing of the symptoms. i would use those symptoms to help guide me to find a nursing diagnosis. a symptom is an objective observation or a subjective perception of the patient and not restricted to be used only by the doctor in formulating his medical diagnosis.

you need to understand how this nursing process is used. first, collect data. second, formulate your nursing diagnoses from the abnormal data you collected. third, plan the care, or, in other words, start adding your nursing interventions. and, so on.

i recommend that you review the information in these three threads on allnurses:

https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)

https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)

https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)

if you have a care plan book or a nursing diagnosis handbook i also recommend that you read over the first chapter(s) where the nursing process is explained. now, is the time that you are expected to start incorporating critical thinking as part of your development of nursing care.

Michelle123 · Sep 28, 2006

They don't really provide much in the way of information related to "Aaron" - yes he is fictional. All we know is basically that he is having disturbed sleep, and that his social interaction has reduced and his communication skills has also been impaired. (which could also be normal adolescent behaviour)

Michelle123 · Sep 29, 2006

Ok, I think I understand now!!

The care plan is based on the nursing diagnosis based on the assessment, but the essay I have to do for it is based on the needs (such as assessment, education, medication review, follow up assessment etc) I was getting confused between what the essay was about and what the care plan was about. Thanks so much everyone for your help!

From what I know from the scenario, Aaron is withdrawn, sleeping a lot and isn't very comunicative. He is in his last year of high school (probably anxious about that) and his mother has just been through a lumpectomy, his sister has recurrant tonsilitis and his father isn't mentioned. So there are a lot of issues. I have sent an e-mail to my teacher for clarification, but I am a little more confident about it now. I'm just doing some readings on the nursing process. I feel so dumb, here I am in second semester of my first year (3 year course) and we haven't really done a lot about the nursing process yet.

Daytonite, BSN, RN · Sep 29, 2006

no! don't feel dumb! this is really kind of complicated stuff. for the first time out doing it, you shouldn't feel that way at all. it takes time and doing a few care plans to get the hang of this. in a learning situation they are a great learning tool. they really do force us to think like a nurse and use critical thinking skills. we weren't born to do that. we have to learn it.

just remember, the care plan is based on what is going on with the patient. keep your focus on the patient and what is going on with him and affecting him. anything else such as the mother's lumpectomy and the sister's tonsillitis are red herrings other than how their disease might affect him. have fun! post if you need more help or have other questions about this. :nurse:

Michelle123 · Sep 29, 2006

Ok, so I'm still unsure now if depression is the nursing diagnosis which I should be looking at interventions for, or if it are the symptoms of depression that I should be using in the care plan?

Also we need to look at one current need and one future need. Just when I think that I am getting my head around it something happens!! I have attached a copy of my care plan with two issues on it.(well I hope it has worked) Would you mind having a look?

Plan of Care Blank-1.doc

Daytonite, BSN, RN · Sep 29, 2006

ok, i am looking at your care plan. let me first say, that in the u.s. we cannot use medical diagnoses as patient problems when we are writing plans of care. i don't know if that is also true in australia. so, the use of the word "depression" would be used on the care plan very carefully.

i took a look at the signs and symptoms of depression and it's treatment. here are the websites i looked at:

http://www.fpnotebook.com/psy63.htm

- major depression

http://www.fpnotebook.com/psy109.htm

- sleep

http://www.fpnotebook.com/psy70.htm

- depression management

http://www.fpnotebook.com/psy71.htm

- depression medical management

in addition, i also have a book here at home that had some information about depression. based on the information you have given in your posts and the information i've been able to put together about depression, this is the list of symptoms i've come up with for aaron:

sleeping a lot (given information) - normal should be 7 to 8 hours a day
reduced social interaction (given information)
impaired communication skills (given information)
withdrawn (given information)
sadness
feelings of hopelessness and/or pessimism, guilt, worthlessness, helplessness
loss of interest in activities that were once enjoyable
loss of energy
fatigue
insomnia (very typical symptom in children)
loss of appetite
mother has had lumpectomy (given information) (does this represent a stressful life event for patient, or helplessness over the situation?)
sister has recurrent tonsillitis (given information)

two thoughts keep playing around in my mind:

sleep and fatigue are major components of major depression
what are the normal activities that someone aaron's age should be engaged in?

all of the above is the data collection. because this is a case scenario and not a real patient, we have to improvise a little. normally, you would find aaron's actual symptoms of his depression in the doctor's history and physical exam or the psychologist's or psychiatrist's exam of him. we have to kind of put one together based on what we know about depression, in general.

next step, would be to take this list of symptoms and look for nursing diagnoses that would accommodate them. right off the bat you saw the problem with sleep. the nanda (north american nursing diagnosis association) nursing diagnosis for this would be: disturbed sleep pattern. however, if you are not using nanda diagnoses, saying "sleeping most of day" will suffice. i might want to be more specific and add a number of hours to that, if known, such as "sleeping 14 hours out of a 24 hour day". the rationale is correct, over sleeping is a symptom of depression.

another symptom he has is isolation. the nanda nursing diagnosis would be: social isolation. again, this is another symptom of depression.

third step in the nursing process is developing your nursing interventions.

for the sleeping:

review aaron's diet and medication. (rationale: something in his diet or a side effect of his medication could be responsible for his extended sleeping.)
review what activities and hobbies aaron used to participate in (rationale: determining which activities he likes will make him more likely to perform these activities.)
encourage aaron to become involved in a physical activity that he likes (such as taking a walk or jogging) (rationale: increasing physical activity will keep aaron from wanting to lie down and sleep.)
if continued long bouts of sleeping continue, refer aaron for psychological evaluation. (rationale: behavior intervention will help aaron to gain greater understanding of his life situation and learn better methods of coping.)

for an outcome, i would list something like, aaron will limit his total sleep time to no more than 8 hours within a 24 hours period. that is in line with what is normal for a person of his age.

here is a link to a list of common anti-depressants:

http://www.globalrph.com/antidepressants.htm

is that perhaps what your instructor was looking for with a medication review? they are listed by their categories. you might want to find the reasons each of those particular category of antidepressants might be ordered and what the expected outcome of taking them should be. for example, tricyclics-tertiary amines, the first group listed, are given to block the reuptake of norepinephrine and serotonin into the nerve endings and increase the action of norepinephrine and serotonin in nerve cells. when given to patients, you would expect to see their depressive behavior improve.

i hope this has given you some direction. because i don't have the advantage of having sat in and listened to your instructor's lectures or seen the written instructions you have, i have to go by what you have told me and what i know from many years of writing care plans. i'm sure you can find a happy medium in there somewhere! if i have helped you, even the slightest bit, i will be thrilled. good luck!

Michelle123 · Oct 1, 2006

Sorry it has taken me so long to reply, I wanted to take it all in and do some research. Thankyou so much for everything!! I think I am starting to understand a little more about the nursing process!! The way you described it may it sound so logical and easy!

Every day I learn that there is a lot more to nursing than most people think and a lot more that goes on behind the scenes than most people realise. I have been working on the essay that goes with this plan too and I feel like I have learnt something from this and I am starting to really enjoy it. There are another couple of scenarios that I have for this subject, and I was thinking of developing care plans for these people as well to practice, I have my last exam on 9th of november so I might get stuck into them then.

Thank you so much for your help on this, I really apreciate it.

M

Daytonite, BSN, RN · Oct 1, 2006

No need to apologize. I'm glad you did some of your own research. That tells me you are working at learning this. I have been known to make a mistake or two anyway so it's a good idea to double check any specific information I've given you. Sometimes hearing the whole thing said by another person in a different way or with different words than a textbook or the way your teachers have explained it will help to make that little light bulb turn on upstairs in the brain. You are learning to think critically. That is what is most important. Critical thinking a learned skill that is not mastered overnight. For most people is not something that comes to them naturally. But when you go into nursing it is right in your face and you have to learn it or you will feel like you are lost and wandering around in a fog trying to find something to help point you in the right direction.