Care plan.. eek!

Esme12, ASN, BSN, RN · Sep 29, 2012

Welcome to AN! The largest online nursing community!

ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. Let the patient/patient assessment drive your diagnosis. Do 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? What are the vital signs? 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? What is important for them to know in the future.

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.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

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. 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.

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: ADPIE

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)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis (ex:confusion) is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis. If we choose the complaint of confusion. For example......... From Gulanick: Nursing Care Plans, 7th Edition

Esme12, ASN, BSN, RN · Sep 29, 2012

Patient:

64 y/o female admitted from ER for hyponatremia. The only thing that was observed when I did a patient assessment was that she was confused, had a few misconceptions about what was going on with her family and their world, she knew her name, where she was, what day it was. I have one DX of Confusion, acute but I need another one! She is on a BP and a depression med. Help!

Is this a real patient? What were the patient complaints? What is hyponatremia? What are the symptoms of hyponatremia? What were the vital signs? What were the labs?

Hyponatremia is an important and common electrolyte abnormality that can be seen in isolation or, as most often is the case, as a complication of other medical illnesses.
Sodium is the dominant extracellular cation and cannot freely cross the cell membrane. Its homeostasis is vital to the normal physiological function of cells. The normal serum sodium level is 135-145 mEq/L. Hyponatremia is defined as a serum level of less than 135 mEq/L and is considered severe when the serum level is below 125 mEq/L.
This article reviews the epidemiology, pathophysiology, differential diagnosis, evaluation, and treatment of this disorder.

medscape is an awesome resource and source. It requires registration but it is free....no strings attached.Medscape: Medscape Access

Hyponatremia

Hyponatremia - MayoClinic.com

We love to help with homework....what do you have so far? Do you have a nursing diagnosis book? what semester are you?

Some resources.....for you........

nursing diagnosis by VickyRN..https://allnurses.com/nursing-student...es-655625.html

Some example of care plans.....

Nursing Care Plan | Nursing Crib

http://www.fresnostate.edu/nursingst...gcareplans.htm

http://www.pterrywave.com/nursing/ca...plans toc.aspx

http://www.snjourney.com/ClinicalInf.../CarePlanN.htm

http://www.delmarlearning.com/companions/content/0766822257/apps/appa.pdf

http://wps.prenhall.com/chet_perrin_...ent/index.html

NP Sam · Sep 30, 2012

You just gave so much info in that paragraph! Esme12 pointed out for you the connection between hyponatremia and confusion. Sometimes it is hard to see that you have everything you need... I hated care plans and nursing diagnoses in school but it has helped me to critically think.

TBrew2014 · Oct 1, 2012

So if I drop the medical dx.. My assessment now is..

I observed a 64 y/o female.. 5'2'' weighing at 128 lbs confused agitated clear lung sounds no signs of edema BP 158/83 auxiliary temp of 100.2 pulse 86 takes a BP and clonazepam. When given her dinner she only ate a few bites and said she was full.

I know I have the Nursing DX of Acute Confusion but I don't know what to use for another one.. I'm not seeing anything..

Esme12, ASN, BSN, RN · Oct 1, 2012

No.....don't drop the medical diagnosis but don't focus on it either. When you follow a recipe do you ignore what your are cooking?

Other than confusion......what other symptoms can be related to hyponatremia? Here is a big piece of information that you left out initially.......what is clonazepam? What side effects can this drug have on a patient? The patients blood pressure is elevated...What makes it elevated? Agitation? (safety) (family disturbance) Is she depressed?(hopelessness)

What is hypertension? HOw does this affect this patient What is depression? Is her poor appetite a sign that she is depressed?

What about the patients safety?(risk for falls) What about her misconceptions about what is going on with the family?(defensive coping) (caregiver role strain)(impaired memory)(Disturbed Sensory perception)

waht is the BMI for 5'2" and 128 lbs...is this ok?

See where I am going?

NP Sam · Oct 3, 2012

Well she spelled it out for you :). As she mentioned, look at all the meds and diagnoses and relate that with symptoms/observations. Esme12 you are AWESOME!