Care map help requested...

in reading through your post i can only come up with 4 actual symptoms, or defining characteristics, that you have listed:

• uses a walker for an unsteady gait
  
• plus 2 edema on her left ankle and leg
  
• heart murmur
  
• shooting pains from the left ankle to the calf

since this patient has a dvt, what are the other symptoms beside pain in the leg? positive homan's? could you palpate a cord? did you get information from the doctor's history and physical exam and review of systems that would have provided you with more symptoms? i'm specifically referring to symptoms pertaining to the patient's hypertension, gerd, asthma and hypothyroidism. what kind of information did you get from the patient when assessing and interviewing the patient in regarding to these conditions? did you interview the patient about how she/he (wasn't sure of the gender of this patient) performs their adls? that's a very nursing thing to assess. all that information has the potential to become symptoms that will contribute to the formation of nursing diagnoses and a plan of care for this person.

you should also have a care plan or nursing diagnosis book to help you in formulating and properly choosing nursing diagnoses. if you do, i strongly urge you to read the first chapter(s) on the nursing process and the process of how to write a care plan. the way nursing diagnoses are chosen is usually discussed pretty extensively in these first chapter(s). each nursing diagnosis has a definition, symptoms (nanda calls them defining characteristics) and related factors. by consulting one of these books you match your patient's symptoms to the nursing diagnoses that are going to fit. it all begins with the assessment data you obtained.

based on the four symptoms you've listed i can formulate these three nursing diagnoses. i've included links to online nursing diagnosis information for each of them where you can get information on outcomes and nursing interventions:

• decreased cardiac output r/t incompetent heart valve aeb heart murmur [your symptoms here should include a description of the heart murmur and where you heard it when you auscultated it] http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=09 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_012.php
  
• ineffective tissue perfusion, peripheral r/t interruption of venous blood flow secondary to dvt aeb 2+ edema in the left ankle and leg and shooting pains from the left ankle to the calf http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=55 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_072.php
  
• impaired physical mobility r/t decreased muscle strength (?) aeb unsteady gait when ambulating requiring the use of assistive device http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=35 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_047.php

you will note that your patient's symptoms become the items that appear after the "aeb" part of each nursing diagnostic statement. that's an important concept that you need to grasp. these same symptoms are the things that you are going to develop nursing interventions for. your outcomes are related to your predictions of what will happen as a result of performing those interventions. so, your outcomes should reflect an improvement, or sometimes just maintaining the status, of a symptom. what follows the "r/t" is always the etiology, or what is the cause, of the symptoms. it is not a medical diagnosis but more of a statement of pathophysiology of why the symptoms have occurred. when you use the words "secondary to" they are added after the etiology part of the diagnostic statement and they almost exclusively name a medical diagnosis. this is the back door, sneaky way that some nursing instructors allow students to show the relationship between the medical diagnosis and the nursing problems. don't use it unless your instructors have told you it is ok to do this. the nursing diagnosis, it's etiology and symptoms that support it are all related to each other.

you can find information about the nursing process and writing care plans on these two 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)

what is important for you to pick up from this whole process is that the whole development of your care plan is based upon the data you collected during your assessment of the patient. this data can come from the doctor's history and physical, his progress notes, any diagnostic procedures that were done, lab results, respiratory therapy notes, physical therapy notes, dietary notes, social service notes, the nursing admission assessment, nursing notes and medication records, as well as what you observed with your own eyes and ears. if your assessment data isn't very good, then you are going to have problems with the care plan. how do you know? when you start to write the care plan things should fall into place because the care plan is a work that reflects rational critical thinking. when you are struggling to piece things together it is because you have missing pieces. those missing pieces are things that got passed over in the data collection. the thinking part of your brain realizes that, but you're not consciously able to see the error that you made. so, i'm here to tell you about it. the steps of care planning are rational and fit together like a lock and key. still, you have to know about each disease the patient has and how it is medically treated, what the medications are that will be given, what is normal physical assessment and what is not. so much needs to be known to put just one care plan together.