Care Plan that counts so much

suzi-Q · Mar 5, 2008

risk for activity intolerance

risk for imbalanced fluid volume

risk for impaired skin integrity

impaired gas exchange

Depends on your assesment...

Good luck

Daytonite, BSN, RN · Mar 6, 2008

hi, rnlill09, and welcome to allnurses! :welcome:

a care plan is all about the nursing problems that a patient has. pneumonia and diabetes are medical problems. difficulty swallowing is a nursing problem. there is a nursing diagnosis for that: impaired swallowing, but the patient has to have at least one of the symptoms of this nursing diagnosis in order for you to assign it to this patient. you can see a list of the symptoms for this diagnosis on this webpage: [color=#3366ff]impaired swallowing.

you cannot even begin to start diagnosing a patient until you have done a thorough assessment and determined the abnormal data (symptoms) that they have. all nursing diagnoses have a defined list of symptoms. where can you find these? in the nanda taxonomy. you can either purchase it from nanda for $25 (nanda-i nursing diagnoses: definitions & classification 2007-2008) or you can frequently find it spread out throughout many of the currently published care plan books that include nursing diagnosis information. nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig has the taxonomy published in it. these two websites have the taxonomy for a limited number of the most commonly used nursing diagnoses that you can access for free on the internet:

you choose a nursing diagnosis based upon its definition, which you should always read, and whether or not your patient has one or more of the symptoms for the diagnosis. nanda calls the symptoms defining characteristics, so you need to get used to seeing that term in the taxonomy. defining characteristics = (is the same as) symptoms. after a while of working with nursing diagnoses you get used to using some of the same ones and it gets easier to assign them. you'll see a group of symptoms and know that they are a particular nursing diagnosis right off the top of your head. but that comes with time and experience.

however, as a student you need to use a reference of some sort. some symptoms will be obvious as being respiratory or circulatory in nature and it will be easier to find the right nursing diagnosis to match with them. others may be a little harder to match. i will admit that there are times when i have gone through my copy of nanda-i nursing diagnoses: definitions & classification 2007-2008 page by page just looking at defining characteristics or the definitions of the diagnoses looking for just the right one to match a patient's signs and symptoms. it happens and that is part of the learning curve. no one knows everything.

in order to determine this patient's nursing diagnoses you need to go back through your assessment data as well as look up information about pneumonia and diabetes. you need to make list of all the symptoms your patient has. then, using that list, match them with nursing diagnoses that have those same symptoms and whose definitions fit with what is going on with the patient.

see these threads that give you very detailed information on how to write a care plan: