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care plan help, please

Hello all, I have nursing diagnosis that I need your opinion on. Thank you.

Disturbed thought process related to impaired judgement as evidenced by delusional statement: "I am not safe at Project Cope, I am only safe at the hospital."

My pt. recently lost custody of her son, because of her drug and psych. problems. She admitted herself to the hospital from substance abuse rehab.

I have several care plans for her, but I am seems to have trouble with care plan that will help her to reunite with her son.

I did my search, but there's not much information on this particular topic.

May I help your advice, please.

LoveMyBugs, BSN, CNA, RN

Specializes in Pediatrics.

Disturbed thought process related to self medicating...maybe.

Look at different nursing diagnosis

How if custody was taken away would a nursing care plan reunite them?

You would need to have involvement of social services and DHS as part of the care plan if her son is in DHS custody.

Just my thoughts, you can help her with coping skills and grieving over the loss of custody

Help her to follow the family reunification plan set out by DHS if there is one.

She had court hearing and six days later admitted with suicidal ideation. I need to cover all aspects of her problems. And it is hard for me to find how I can address situation with her child.

Thank you for your comment.

Esme12, ASN, BSN, RN

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

Hello all, I have nursing diagnosis that I need your opinion on. Thank you.

Disturbed thought process related to impaired judgement as evidenced by delusional statement: "I am not safe at Project Cope, I am only safe at the hospital."

My pt. recently lost custody of her son, because of her drug and psych. problems. She admitted herself to the hospital from substance abuse rehab.

I have several care plans for her, but I am seems to have trouble with care plan that will help her to reunite with her son.

I did my search, but there's not much information on this particular topic.

May I help your advice, please.

Is her statement
"I am not safe at Project Cope, I am only safe at the hospital."
delusional? Or is it a real statement of her potential to self harm?

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.

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

  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)

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.

Now...tell me about your patient.

Esme12, ASN, BSN, RN

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

All nursing diagnosis must come from NANDA. Each diagnosis has definitions and criteria that must be fulfilled by the patient assessment....here are some I would think apply. What care plan resource do you use?

Risk for Suicide

Stress overload

Chronic low Self-Esteem

Parental Role Conflict

Impaired individual Resilience

Hopelessness

Ineffective Coping

Caregiver Role Strain

Hi, my pt. 26 y.o. with medical diagnosis: Bipolar, mixed cluster B personality d/o, Complex PTSD, adjustment d/o with mixed features, panic disorder, opioid dependence, marijuana abuse and impulse control d/o.

Chief complaint: "I've been feeling suicidal for about a week. I wouldn't be safe going back to project cope- I'd stick a knife into my throat." And reason for hospitalization was: Risk for suicide, depression.

For my school project I need to use functional health pattern classification and have 4 care plans from different categories.

I have:

1. Risk for suicide related to depression as evidenced by patient statement: "I've been feeling suicidal for about a week now..."

2. Hopelessness related to loss of custody of 2 y.o. son as evidenced by pt. stating: "He was my life, I cant go without him."

3. Disturbed thought process related to impaired judgement as evidenced by delusional pt. statement: "I am not safe at project cope, I am only safe at the hospital"

4. Ineffective health maintenance related to substance dependence as evidenced by pt. long Hx. of drug use.

5.Dysfunctional grieving related to loss of custody of a son, as evidenced by suicidal ideation.

My patient has Hx of two suicide attempts in the past. And statements are her own from the chart.

Thank you.

la_chica_suerte85, BSN, RN

Specializes in Pediatric Hematology/Oncology.

If your focus is going to be on the pt eventually being able to get custody back, then you need to start very basic. First, she has to be able to take care of herself appropriately. So, I think the assessment of ADLs functionality would be ideal. The major one at the moment, though, would be the "Risk for Suicide" -- there have to be functional patterns (i.e. the drug use) and causes or factors related to these patterns (i.e. mental health problems) that can also be assessed and dealt with. What can you do to actively help a pt like this? Wanting to help her be reunited with her son is no quite where that focus is -- that is a motivation for the pt but she has some serious unpacking to do with herself before that even can potentially become a reality. The unpacking is not something you can actually do but you can facilitate that (i.e. social services contact).

If your focus is going to be on the pt eventually being able to get custody back, then you need to start very basic. First, she has to be able to take care of herself appropriately. So, I think the assessment of ADLs functionality would be ideal. The major one at the moment, though, would be the "Risk for Suicide" -- there have to be functional patterns (i.e. the drug use) and causes or factors related to these patterns (i.e. mental health problems) that can also be assessed and dealt with. What can you do to actively help a pt like this? Wanting to help her be reunited with her son is no quite where that focus is -- that is a motivation for the pt but she has some serious unpacking to do with herself before that even can potentially become a reality. The unpacking is not something you can actually do but you can facilitate that (i.e. social services contact).

Hi, thank you for your response.

What I would like to do is to find a way to help her to have a hope having her child, actually I would like her to have supervised visitation. She is not stable to be with a child on her own, too many issues, but research has sown that mother with addiction problems benefit in having closer relationship with their children. It will be good for a little boy (2y.o) know that mom is around and she loves him, which I think she does and she can have a stimuli to get off drugs and comply with meds and treatment.

Thank you for your responses and suggestions. You can see that I have some nursing diagnosis in mind but I am not sure that they are NANDA approved :)

Thank you.

Esme12, ASN, BSN, RN

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

If you had the NANDA resource you would know if they were NANDA approved.....http://www.amazon.com/Nursing-Diagnoses-2015-17-Classification-International/dp/1118914937/ref=sr_1_1?ie=UTF8&qid=1416597141&sr=8-1&keywords=NANDA

There are possibilities....Caregiver Role Strain is one. You can't give her false hope. She must face and deal with her addiction issues and prove worthy to the courts that she can be reliable. You don't decide about visitation the courts do. YOu can help the patient setting obtainable goals for her own health/behavior to "prove" she can be around her son. That is what the care plan needs to reflect.

Sleep deprivation related to depression as evidenced by nightmares.

What do you guys think about this one?

Esme12, ASN, BSN, RN

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

As I have stated....care plans are all about the patient assessment. Many students fall into the trap of looking at a list of nursing diagnoses and think "Hey that sounds like a good one!" and try to retro fit the patient into they diagnosis. Remember a physician doesn't look at a patient and say....."I think cancer is a fancy diagnosis now lets see if she has it".

You have provided medical diagnosis but a care plan is about the patient....mo where in this post have you mentioned the patient has trouble sleeping. You have no provided an assessment of your patient so it is difficult to impossible to help you.

Sleep deprivation is NOT a NANDA diagnosis....it is disturbed sleep pattern

NANDA Definition: Time-limited disruption of sleep (natural periodic suspension of consciousness)

Defining Characteristics: Prolonged awakenings; sleep maintenance insomnia; self-induced impairment of normal pattern; sleep onset >30 minutes; early morning insomnia; awakening earlier or later than desired; verbal complaints of difficulty falling asleep; verbal complaints of not feeling well-rested; increased proportion of Stage 1 sleep; dissatisfaction with sleep; less than age-normed total sleep time; three or more nighttime awakenings; decreased proportion of Stages 3 and 4 sleep (e.g., hyporesponsiveness, excess sleepiness, decreased motivation); decreased proportion of REM sleep (e.g., REM rebound, hyperactivity, emotional lability, agitation and impulsivity, atypical polysomnographic features); decreased ability to function

Related Factors: Ruminative presleep thoughts; daytime activity pattern; thinking about home; body temperature; temperament; dietary; childhood onset; inadequate sleep hygiene; sustained use of antisleep agents; circadian asynchrony; frequently changing sleep-wake schedule; depression; loneliness; frequent travel across time zones; daylight/darkness exposure; grief; anticipation; shift work; delayed or advanced sleep phase syndrome; loss of sleep partner, life change; preoccupation with trying to sleep; periodic gender-related hormonal shifts; biochemical agents; fear; separation from significant others; social schedule inconsistent with chronotype; aging-related sleep shifts; anxiety; medications; fear of insomnia; maladaptive conditioned wakefulness; fatigue; boredom

Environmental :Noise; unfamiliar sleep furnishings; ambient temperature, humidity; lighting; other-generated awakening; excessive stimulation; physical restraint; lack of sleep privacy/control; interruptions for therapeutics, monitoring, lab tests; sleep partner; noxious odors

Parental :Mother's sleep-wake pattern; parent-infant interaction; mother's emotional support

Physiological :Urinary urgency, incontinence; fever; nausea; stasis of secretions; shortness of breath; position; gastroesophageal reflux

Esme12, ASN, BSN, RN

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

I am going to quote a friend and contributor here Grntea.....

Students often fall 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. 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.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro.

That situation makes me want to cry. :( She sounds like she's been through the ringer. I agree, that doesn't sound like a delusional statement; she's expressing intent to self-harm.

About wanting her to have visitation and ultimately reunite...keep in mind that with nursing interventions, you have to look at things you can actually do or make happen. I do hope she gets the help she needs and is able to care for her own son. But visitation and custody issues are 100% outside a nurse's control. The NIC book is a good resource, and I agree that your focus should be on helping her cope and helping her with self-care so that hopefully she can get to a place where she is able to care for her son.

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