care plan help, please

LoveMyBugs, BSN, CNA, RN · Nov 20, 2014

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.

victoriyad · Nov 20, 2014

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 · Nov 20, 2014

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

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.

Now...tell me about your patient.

Esme12, ASN, BSN, RN · Nov 20, 2014

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

victoriyad · Nov 20, 2014

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 · Nov 21, 2014

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).

victoriyad · Nov 21, 2014

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 · Nov 21, 2014

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.

victoriyad · Nov 21, 2014

Thank you.

victoriyad · Nov 23, 2014

Sleep deprivation related to depression as evidenced by nightmares.

What do you guys think about this one?

Esme12, ASN, BSN, RN · Nov 23, 2014

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