Care plan help please

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Hello everyone I am a first year nursing student and I stalk this web page often to get ideas on how to do things since my instructor tells me to look it up in the book. I am having issues with my care plan. Here goes My patient is 32 presented in the ER with severe abdominal pain. Long story short. He was admitted and had small bowel obstruction. He has been NPO for three days NG tube in place, constipated and not passing gas at all. He has been ambulating 4x a day up and down the halls to get things moving along but nothing. Anyways I have to do 2 problems on him and I chose :Impaired skin integrity R/T interruption of skin and tissues, AEB vertical abdominal incision. I was trying to do Constipation R/T decreased motility AEB, abdominal distention and no bowel movement for 3 days. Most of the things to assess for are for patients that are not NPO like my patient. How can I assess things such as eating pattern, fluid intakes, elimination pattern etc.... please I need advise I have been thinking about this for too long and now it is due tomorrow 8 a.m. I did do my second problem on nutrition more than body requirements but I was told his obesity is not important. Thank you candace

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Do you have the NANDA-I 2012-2014? You can get it instantly at Amazon for your Kindle or iPad for $25 and it will save your life because it is, quite literally, the only nursing diagnosis book.

If you have lurked around this website enough, you ought to have found the student nurse forum, and that is where you should be. I promise you there are a lot of care planning threads there.

Someone with his presentation has several problems. Put down your list of medical diagnoses and look at him, your unfortunate, miserable, how-the-heck-did-this-hapen-to-me patient. What are they? If you were just fresh postop after a bowel resection or whatever he had, with a big incision on your belly and an NG tube, how would you feel? What would you feel and think? Why? What does nursing have to offer you? Does your belly hurt? Do you feel like a truck hit you? Do you feel weak? Are you scared? Are you worried about your kids at home? Do you wonder what you will have to do when you get out of the hospital? Do you have any other medical conditions or habits that could lead to complications?

See, without doing all that looking at the actual patient you are falling into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

In all fairness, we see ample evidence every day that nursing faculty sometimes have a hard time communicating this concept to new nursing students. So my friend Esme and I do our best to reboot you and get you started on the right path. :)

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts should come first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle or iPad at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised! Wonder where you learned that??? :)

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. Sometimes they're out of date, too-- NANDA-I is reissued and updated q3 years, so if your "handbook" is before 2012, it may be using outdated diagnoses.

We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings and at least one of the related / caustive factors are present. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.

Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. It would probably have something to do with no increase in pain due to decreased circulation, or perhaps no increase in tissue injury, you might also consider some of the educational components, so one of your outcomes might be that the patient describes…, so you understand that he knows more about his disease.

I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Let this also be your introduction to the idea that just because it wasn't on your bookstore list doesn't mean you can’t get it and use it. All of us have supplemented our libraries from the git-go. These three books will give you a real head-start above your classmates who don't have them.

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Thank you so much for your input I will refer to this often I'm sure. I do have a couple of outdated care plan books and I will get the most up to date one. Our instructor will not permit us to use a care plan book until next semester, so all I have been using is my Fundamentals of Nursing book (Taylor) and the Med-Surge book (Iggy). I think she has completely forgotten that she was in my shoes at one time because she gives no extra insight on anything except her red ink all over my care plans lol. Thank you again for your help I'm sure you will hear from me often(at least this year) until I get the hang of these things.

Thank you bunches.

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The reason your instructor doesn't want you to use a "care plan book" is because all of them except the NANDA-I classify nursing diagnoses by medical diagnoses, and she doesn't want you to get into that habit. This is a good thing.

However, you should have the NANDA-I 2012-2014 regardless, and use it, and don't stop using it even if they assign you another "care plan handbook." The NANDA,NOC,NIC suggests and classifies interventions by nursing diagnosis, which is really what you want if you want to learn to think like a nurse, not a medical adjunct. She may not have seen these-- share, and see what she thinks after you explain all this. :)

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Where did you find NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions? I'm looking on Amazon and I'm trying to find the most recent edition, and I'm not sure which one is the most recent.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you so much for your input I will refer to this often I'm sure. I do have a couple of outdated care plan books and I will get the most up to date one. Our instructor will not permit us to use a care plan book until next semester, so all I have been using is my Fundamentals of Nursing book (Taylor) and the Med-Surge book (Iggy). I think she has completely forgotten that she was in my shoes at one time because she gives no extra insight on anything except her red ink all over my care plans lol. Thank you again for your help I'm sure you will hear from me often(at least this year) until I get the hang of these things.

Thank you bunches.

Using old books will NOT help you. They do not have the current NANDA I diagnosis information/taxonomy/definitions/characteristics which changes time to time.
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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Care plans are all about the patient and the patients problems. 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 patient saying?. 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. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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.

  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)

Tell me your assessment...What does this patient need? Tell me about your patient....you have told me what is wrong with him but nothing about your assessment.
chuggins997 Hello everyone I am a first year nursing student and I stalk this web page often to get ideas on how to do things since my instructor tells me to look it up in the book. I am having issues with my care plan. Here goes My patient is 32 presented in the ER with severe abdominal pain. Long story short. He was admitted and had small bowel obstruction. He has been NPO for three days NG tube in place, constipated and not passing gas at all. He has been ambulating 4x a day up and down the halls to get things moving along but nothing. Anyways I have to do 2 problems on him and I chose :Impaired skin integrity R/T interruption of skin and tissues, AEB vertical abdominal incision. I was trying to do Constipation R/T decreased motility AEB, abdominal distention and no bowel movement for 3 days. Most of the things to assess for are for patients that are not NPO like my patient. How can I assess things such as eating pattern, fluid intakes, elimination pattern etc.... please I need advise I have been thinking about this for too long and now it is due tomorrow 8 a.m. I did do my second problem on nutrition more than body requirements but I was told his obesity is not important. Thank you candace

constipation is a good diagnosis and I think you are on the right track here.

NANDA I describes constipation as...Decrease in normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

Defining Characteristics: Feeling of rectal fullness; feeling of rectal pressure; straining with defecation; unable to pass stool; abdominal pain; abdominal tenderness; anorexia; atypical presentations in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); borborygmi; change in bowel pattern; decreased frequency; decreased volume of stool; distended abdomen; generalized fatigue; hard, formed stool; headache; hyperactive bowel sounds; hypoactive bowel sounds; increased abdominal pressure; indigestion; nausea; oozing liquid stool; palpable abdominal or rectal mass; percussed abdominal dullness; pain with defecation; severe flatus; vomiting:

Related Factors (r/t)

Functional

Abdominal muscle weakness; habitual denial; habitual ignoring of urge to defecate; inadequate toileting (e.g., timeliness, positioning for defecation, privacy); irregular defecation habits; insufficient physical activity; recent environmental changes

Psychological

Depression, emotional stress, mental confusion

Pharmacological

Aluminum-containing antacids; anticholinergics, anticonvulsants; antidiarrheal agents, antidepressants, antilipemic agents, bismuth salts, calcium carbonate, calcium channel blockers, diuretics, iron salts, laxative overdose, nonsteroidal antiinflammatory drugs (NSAIDs), opioids, phenothiazines, sedatives, and sympathomimetics

Mechanical

Neurological impairment, electrolyte imbalance, hemorrhoids, Hirschsprung’s disease, obesity, postsurgical obstruction, pregnancy, prostate enlargement, rectal abscess, rectal anal fissures, rectal anal stricture, rectal prolapse, rectal ulcer, rectocele, tumors

Physiological

Change in eating patterns, change in usual foods, decreased motility of gastrointestinal tract, defecation disorder, dehydration, inadequate dentition, inadequate oral hygiene, insufficient fiber intake, insufficient fluid intake, poor eating habits

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

now impaired skin intergity...

NANDA describes impaired skin integrity...Altered epidermis and/or dermis

Defining Characteristics: Destruction of skin layers; disruption of skin surface; invasion of body structures

Related Factors (r/t):

External

Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical immobilization; radiation

Internal

Changes in fluid status; changes in pigmentation; changes in turgor; developmental factors; MAYBE.... imbalanced nutritional state (e.g., obesity, emaciation, chronic disease, vascular disease); immunological deficit; impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence

other than a surgical wound what related to factor does you patient have to fit this diagnosis?

Now....is your patient hydrated? Do they have IVF? DO they ahve a Foley? Are they in pain? Are they receiving pain RX? IV antibiotics? Are they receiving any nutrition IV? What is their output? Without "knowing and assessing the patient here is what might apply.

Delayed Surgical Recovery unable to move bowels extended hospital stay

Acute Pain

Imbalanced Nutrition: less than body requirements for healing

Risk for Electrolyte Imbalance has NGT

Do you see where your instructor wants this to go?

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Thank you GrnTea!! I found it and was able to get the boos you recommended! I should have them by Wednesday!!

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Thank you GrnTea!! I found it and was able to get the boos you recommended! I should have them by Wednesday!!

Oh my ... the boos? =) The way that sounded made me think of the common social lubricant, typically taken PO.

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Lmao!! That was supposed to be books!!

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