Care plan feedback

[jrsygrl76]

Hi all!

This is my first post. I have been on this site for about 6 months and have gotten some great information! I appreciate all that you guys do.

I have a care plan that I need to do for an AIDS patient and I'm having some trouble with it.

Here is the info and what I have done so far:

Client has AIDS that she contracted from her spouse who often travels for work. Her HIV status has converted to AIDS. SHe is currently experiencing a yeast infection in her mouth that is very painful. She has not been able to eat and her only intake is ice chips. She complains of feeling weak and dizzy. She would like to attend her sister's baby shower but knows her nieces and nephews will be there. Someone is always sick. Her sister and mother are extremely supportive and willing to do anything to enhance her quality of life.

I need to have 2 nursing diagnosis with 2 goals and 3 interventions for each diagnosis.

My first diagnosis is:

Acute pain r/t yeast infection aeb ability to eat only ice chips

I'm having trouble with this one because all the info I have found is how to avoid getting thrush and not good alternatives to treat except for medications prescribed by doctor

Second diagnosis:

Social isolation r/t infection control practices aeb fear to attend sister's baby shower

(I've got this one done)

Any feedback (positive or negative) would be greatly appreciated!

[pghnurse527]

I think those are both good nursing diagnoses. I would consider adding a diagnosis that is directly related to the patient's physiologic state rather than emotional/MH state. Interventions do not all have to be things you did to 'correct' the problem. Assessing is an intervention. I'd start there.

[Esme12, ASN, BSN, RN]

do you have a care plan book? you need a good one. 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:

1. 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)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

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.

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 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?

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 them as a recipe to caring for your patient. your plan of how you are going to care for them.

from a very wise an contributor 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.

check out this link.

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

now for your patient.......how about imbalanced nutrition or impaired oral mucus membrane? is she getting enough nutrients through the ice chips. does she have interrupted family process? what teaching does she need?

nanda defines

imbalanced nutrition: less than body requirements

nanda-i definition: intake of nutrients insufficient to meet metabolic needs

impaired oral mucous membrane

nanda-i definition: disruption of the lips and/or soft tissue of the oral cavity

acute pain

nanda-i definition: unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (international association for the study of pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

interrupted family processes

nanda-i definition: change in family relationships and/or functioning

care plans are to 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. i also think the instructors do a disservice by giving scenarios since the care plan is based on the patient's needs and assessment....here are 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