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Atrial septal defect care plan

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by burnsie15 burnsie15 (New) New

Today I observed an atrial septal defect repair on a 3mo old using a cardiac catheter and my professor wants me to write a care plan for this patient. I am completely stuck. Any ideas for the diagnosis and maybe I could figure it out from there?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

first what is asd. what symptoms does it cause? how does it present in a 3 month old? what should you look for post op? what would the post op care be for this procedure? what do you have so far?

pediatric atrial septal defects (requires registration that is free)

]medscape: medscape access

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 plan:

  1. 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)
  2. 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)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

https://allnurses.com/nursing-student-assistance/first-care-plan-689164.html#post6283634

what do you have do far?

don't forget for an instant that your nursing plan of care also includes the parents. check in your nanda-i 2012-2014 (which every student should have even if it's not assigned, and you can get at your favorite online bookseller) and look under the headings for stress/coping, role, and life principles. i promise you'll be glad you did.