Care Plan Etiology HELP!

ParkerBC,MSN,RN, PhD, RN · Oct 17, 2013

Not to sound mean, but do you know what etiology means? If so, what are some of your thoughts based upon the information presented?

losilva95 · Oct 17, 2013

It's the cause. I'm just having trouble with the whole thing about "can you fix the cause" Im stumped on this one.

Esme12, ASN, BSN, RN · Oct 17, 2013

There is not enough information here for us to help you. Why was the patient admitted? Out of everything wrong with the patient this is the priority?

Care plans are all about the patient assessment. What semester are you? What care plan book do you use.

You tell us what you have come up with and why....tell me about your patient.

She is a ab years old with a history of....who came in for.....vitals.....assessment....she complains about....

Or...if this is not a real patient what information were you given

MendedHeart · Oct 17, 2013

Related to loss of loved one?

Related emotional instability?

Related to fear of social situations?

Kind of need more info like the Nursing Dx you are using to start, and maybe more assessment info

losilva95 · Oct 17, 2013

I'm a a first year student, first care plan ever! She's presented with a left abdominal abscess. She's 87 yrs old, and underweight. Arthritis in hands. No other previous/current illness. Pt is healthy overall. Ambulates without assist. Is able to perform ADL's on her own. When asked about church or friends she said she didn't have any friends or attend church. She lost her husband years ago and stated she coped well. She has a "ranch" with chickens, ducks, goats, cows, and one horse. She spends all her time taking care of them and says she doesn't have time for anything else. Her 3 daughters live in California. One daughter doesn't even acknowledge her. Her only son is the one who's always been there when she needs something. She stated she eats 1-2 meals a day and forgets to eat because she's so busy. She enjoys eating fruits and veggies. Rarely eats beef or pork. BM are daily.

NurseRose84 · Oct 17, 2013

Im a first semester student too! These care plans are going to be the bane of my existence, I can tell! I get why our instructors have us do them though.

As for your situation, your patient is underweight, and says that many times she forgets to eat because she is so busy. Also, she just underwent surgery for an abdominal abscess. Is she in any pain?

Pain and food are both physiological needs and, as such are considered more important in Maslow' Heirarchy. Although a sense of belonging and risk for loneliness are important, I would probably focus more on her nutritional deficits as she is at risk for inadequate nutritional intake since she doesn't eat meat very often. Maybe she needs more protein in her diet, especially since she is older.

If she's in pain though, I would probably focus on that. Dx of "acute pain related to surgical incision secondary to abdominal abscess AEB pain intensity rating of #out of ten, etc."

Good luck in school! Hope we both make it out unscathed!

Esme12, ASN, BSN, RN · Oct 17, 2013

I'm a a first year student, first care plan ever! She's presented with a left abdominal abscess. She's 87 yrs old, and underweight. Arthritis in hands. No other previous/current illness. Pt is healthy overall. Ambulates without assist. Is able to perform ADL's on her own. When asked about church or friends she said she didn't have any friends or attend church. She lost her husband years ago and stated she coped well. She has a "ranch" with chickens, ducks, goats, cows, and one horse. She spends all her time taking care of them and says she doesn't have time for anything else. Her 3 daughters live in California. One daughter doesn't even acknowledge her. Her only son is the one who's always been there when she needs something. She stated she eats 1-2 meals a day and forgets to eat because she's so busy. She enjoys eating fruits and veggies. Rarely eats beef or pork. BM are daily.

Ok.....so your patient is admitted for an abdominal abscess. Is this resolved? What have they done to treat the illness? What meds is she on? Does she have pain? What does she complain of?

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.

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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.

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 is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

MendedHeart · Oct 17, 2013

Im pretty sure the OP has other Nursing Diagnoses, Im assuming anyway, and just stumped on this specific part of this one ND??

Again, What are you saying is a problem here?

She doesn't appear to have a psych/social issue here from the data you presented

You said that shes been earing fine since in the hospital right?

Can an Abcess/infection affect appetite? Did she get ABX?

If shes eating adequate now, it wouldn't need to be addressed

nurseprnRN, BSN, RN · Oct 17, 2013

Is she giving you any actual evidence that social isolation is a problem for her? You don't mention any, but I can't tell if you have seen some of the defining characteristics of the diagnosis that would let you make it. Maybe you did.

I'm looking in the NANDA-I 2012-2014 at that diagnosis. It says:

Definition: Insufficient or excessive quantity or ineffective quantity of social exchange

However, that doesn't mean that you get to determine what's insufficient, excessive, or ineffective. She does. Let's look at the defining characteristics; does she meet any?

Discomfort in social situations

Dysfunctional interactions with others

Family reports changes in interaction (e.g., style, pattern)

Inability to communicate a satisfying sense of social engagement (e.g., belonging, caring, interest, shared history)

Inability to receive a satisfying sense of social engagement (e.g., belonging, caring, interest, shared history)

Use of unsuccessful social interaction behaviors

Are/is defining characteristics because of:

Related (causative) factors:

Absence of significant others

Communication barriers

Deficit about ways to enhance mutuality (e.g., knowledge, skills)

Disturbed thought processes

Environmental barriers

Limited physical mobility

Self-concept disturbance

Sociocultural dissonance

Therapeutic isolation

Causative factor is the definition of etiology. :)

ParkerBC,MSN,RN, PhD, RN · Oct 18, 2013

Sorry I did not get back to you! :-( After reading the other responses, I concur. I hope you found the information needed to be successful on your care plan. Good luck to you in your current and future courses!

Esme12, ASN, BSN, RN · Oct 18, 2013

I'm a a first year student, first care plan ever! She's presented with a left abdominal abscess. She's 87 yrs old, and underweight. Arthritis in hands. No other previous/current illness. Pt is healthy overall. Ambulates without assist. Is able to perform ADL's on her own. When asked about church or friends she said she didn't have any friends or attend church. She lost her husband years ago and stated she coped well. She has a "ranch" with chickens, ducks, goats, cows, and one horse. She spends all her time taking care of them and says she doesn't have time for anything else. Her 3 daughters live in California. One daughter doesn't even acknowledge her. Her only son is the one who's always been there when she needs something. She stated she eats 1-2 meals a day and forgets to eat because she's so busy. She enjoys eating fruits and veggies. Rarely eats beef or pork. BM are daily.

Your assessment...you physical assessment. Skin warm and dry? Does she have a fever? Does she had an IV/antibiotics? did they perform surgery? What was the abscess from? Did they drain it? what caused the abscess? What did she present to the hospital with?

What is her main complaint? Attached is a critical thinking flow sheet for students made by our dear Daytonite....on how to "think about" your patient assessment.

Critical Thinking Flow Sheet for Nursing Students.doc