Care plan books

Esme12, ASN, BSN, RN · May 10, 2012

Welcome to AN! The largest online nursing community!

I like Gulanick....do you have the care plan constructor? I also like Ackley: Nursing Diagnosis Handbook, 9th Edition. I/We help with a ton of care plans here what are you confused about? Let us help.

pupcik2000 · May 10, 2012

my patient has Down syndrome, she is non-verbal and immobile. my professor would like me to use self care deficit R/t impaired physical mobility evidences by compromised ADL ROM limitations. im stuck on goals. i wrote short term goal as patient will be turned in bed q2h to prevent pressure ulcers, but i dont know where to go with her long term goal.

OB-nurse2013, BSN, RN · May 10, 2012

I love my Ackley book that Esme mentioned above. I use it religiously and I'm going into my 4th semester :) Careplans are difficult but once you get the hang of it, they become much easier! Hnag in there and find a book that works for you.

Enthused RN, BSN, RN · May 11, 2012

A little while back a nurse on AN said that sometimes the goal isn't to improve/cure their condition but to maintain their current level of function (or something along those lines). So for your patient, perhaps a long term goal can be preventing a further loss of function (i.e. contractures, etc.)

mssjez · May 11, 2012

I am just a nursing student, and don't have much experience in care plans, but I've spent the past five years working with individuals with disabilities. One of the primary aspects of DS in terms of diagnosis and treatment is significantly decreased muscle tone which leads to decreased function and ROM. What can you do for this primary influence of ADL functioning?

nurseprnRN, BSN, RN · May 11, 2012

every student should have the nanda-i 2012-2014 (most current edition) to learn nursing diagnoses. you cannot, cannot, cannot write a nursing diagnoses and interventions from a medical diagnosis.

this does not mean that there is a magic list of medical diagnoses from which you can derive nursing diagnoses. nothing is farther from the truth.

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 some 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, so read on.

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.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

so, you don't think of a diagnosis for your patient and then go searching for supporting data. you collect data and then figure out a nursing diagnosis.

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

Esme12, ASN, BSN, RN · May 12, 2012

welcome to an! the largest online nursing community!

grtea always gives great advice. so, your professor wants you to use this diagnosis. in the future........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? is the the patient having pain? are they having difficulty with adls? what teaching do they need? 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 the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. what would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

from a very wise an contributor daytonite.......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.

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 plan:

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.

https://allnurses.com/nursing-student...is-290260.html

so your patient with downs is immobile and would need to have meticulous skin care to prevent breakdown right? active/passive rom to prevent further contractures, right? what would you like to see for this patient in the future? minimal/no skin issues and no contractures, right? does the patients incontinence impose a risk?

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. some other helpful links.

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

understanding the essentials of critical care nursing