Care Plan help Please

nurseprnRN, BSN, RN · Jan 25, 2015

(I stupidly let a friend borrow my NANDA books and haven't seen them since.)

Let her keep it. Unless it was the 2015-2017, you need the new one anyway. :)

CT Pixie, BSN, RN · Jan 25, 2015

Let her keep it. Unless it was the 2015-2017, you need the new one anyway. :)

Figured she needed it more than I did. I graduated and have had little use for it since beginning work. I can honestly say I've had no need to sit and write a care plan.

nurseprnRN, BSN, RN · Jan 25, 2015

Figured she needed it more than I did. I graduated and have had little use for it since beginning work. I can honestly say I've had no need to sit and write a care plan.

Ah, but just because you don't have to write one in school format, you have every reason to keep learning about nursing diagnoses so you can apply it in your professional life. I've been out of school mumblemumble years and I use it all the time, and if anyone questions my judgment I have backup. You can learn a helluva lot from the 2015-2017 edition. I double-dog dare ya! :)

CT Pixie, BSN, RN · Jan 25, 2015

A common but dangerous (yes, really) misconception. If you look at the NANDA-I 2015-2017 (and indeed, all previous editions) you will find a whole section devoted to safety-related diagnoses. Almost all of them are "risk for" diagnoses, and why are patients in our care if not to keep them safe? Patients at risk for bad things are at risk for bad things, not to belabor the obvious. These could well be the priorities in their care. Look at that statement, think about it.

Ameliorating or preventing things for which the patient can be at risk can very well be the priorities in their care.

I do understand there is a whole section for safety-related dx. Of course safety is very important, I get that 100%. I was simply stating what my CI's drilled into our heads during my LPN and RN schooling. They did not want 'risk for impaired skin integrity' when the patient had actual problems going on such as ineffective airway clearance or decreased cardiac output. Normally we were told 5 'actuals' and 1 'risk for' NANDA. I was just stating what I was taught. :)

CT Pixie, BSN, RN · Jan 25, 2015

Ah, but just because you don't have to write one in school format, you have every reason to keep learning about nursing diagnoses so you can apply it in your professional life. I've been out of school mumblemumble years and I use it all the time, and if anyone questions my judgment I have backup. You can learn a helluva lot from the 2015-2017 edition. I double-dog dare ya! :)

Ahhh GrnTea, normally I would accept a double-dog dare, but I do agree with you. While I don't 'write' them out anymore, they are always in my head on what I need to do intervention wise in order to best care for my patients.

nurseprnRN, BSN, RN · Jan 25, 2015

^^^ THIS. :anpom: :anpom: :anpom: :anpom: :anpom:

Brava. Students, are you paying attention?

nurseprnRN, BSN, RN · Jan 25, 2015

I do understand there is a whole section for safety-related dx. Of course safety is very important, I get that 100%. I was simply stating what my CI's drilled into our heads during my LPN and RN schooling. They did not want 'risk for impaired skin integrity' when the patient had actual problems going on such as ineffective airway clearance or decreased cardiac output. Normally we were told 5 'actuals' and 1 'risk for' NANDA. I was just stating what I was taught. :)

Whatever happened to "priorities"? Don't they ask you to justify your diagnoses when you make them, or do they just want a list that you picked out of the book in the order in which they were printed?

If you have someone with, oh, spinal cord injury, you'd better believe that skin integrity is huge even if she's in for a minor GYN surgery. Since the risk of serious consequences for skin breakdown in SCI is worse than for many other people, I would argue that putting skin observation, skin care, positioning, pressure releases, and nutrition are absolutely top of the list.

CT Pixie, BSN, RN · Jan 25, 2015

And GrnTea, for what its worth....safety is always #1 in my head as I do bedside report as well as when I am in and out of my patients hospital roooms. My eyes dart around to be sure the bed/chair alarms are indeed on, the IV pumps are out of the way, making sure the IV tubing isn't wrapped around an arm cutting off circulation or heaven forbid.., making sure the O2 tubing isn't wrapped around ones neck (yes, I've seen this happen..while working as an LPN my little old man in LTC, somehow wrapped the tubing around his neck like a necktie and was tightening it as I was doing a 'look-see' down my hall.) Making sure the call bell is within reach..all the things that are often over looked but can be the make or break of a patients safety.

nurseprnRN, BSN, RN · Jan 25, 2015

Oh, no doubt in my mind. I just wanted to enlighten the students who may believe that "actual" is more important than "risk for." :) (And perhaps their faculty since it seems to be an ongoing misconception.)

CT Pixie, BSN, RN · Jan 25, 2015

Whatever happened to "priorities"? Don't they ask you to justify your diagnoses when you make them, or do they just want a list that you picked out of the book in the order in which they were printed?

If you have someone with, oh, spinal cord injury, you'd better believe that skin integrity is huge even if she's in for a minor GYN surgery. Since the risk of serious consequences for skin breakdown in SCI is worse than for many other people, I would argue that putting skin observation, skin care, positioning, pressure releases, and nutrition are absolutely top of the list.

We had to have findings that backed up our nursing dx and they wanted them listed in order of priority (Airway, breathing circ order and Maslow). But as I said they wanted 'actuals' before 'risk fors'.

Don't kill the messenger I totally get what you are saying :) While you are correct about the skin intergrity of a SCI is pretty high up in the matter of priority, if I ever tried to 'argue' with a CI it wouldn't have been pretty. I suppose they were trying to get us to use our brains. I think a lot of people would just list a bunch of 'risk for's because they didn't require an AEB info. Who knows...now that I am on my own and left to my own critical thinking, I know what to keep in mind to keep my patients safe as well as what I need to do to best help in their healing/recovery.

nurseprnRN, BSN, RN · Jan 25, 2015

We had to have findings that backed up our nursing dx and they wanted them listed in order of priority (Airway, breathing circ order and Maslow). But as I said they wanted 'actuals' before 'risk fors'.
Don't kill the messenger I totally get what you are saying :) While you are correct about the skin intergrity of a SCI is pretty high up in the matter of priority, if I ever tried to 'argue' with a CI it wouldn't have been pretty. I suppose they were trying to get us to use our brains. I think a lot of people would just list a bunch of 'risk for's because they didn't require an AEB info. Who knows...now that I am on my own and left to my own critical thinking, I know what to keep in mind to keep my patients safe as well as what I need to do to best help in their healing/recovery.

No messenger-shooting going on here. :)

But risk diagnoses do have requirements analogous to AEB in non-risk diagnoses ... for identifying actual (!) risk factors. If I recall correctly, the OP's patient had a heparin gtt going, and may have had other things going on. If I were her CI, I'd be pleased as punch that she noticed these and came to the conclusion that they could be significant in terms of injury risk. I would never accept a random list of risk diagnoses with boilerplate justifications as if they were meaningful, if they didn't fit the actual assessment of the patient. :: sigh :: Perhaps I just wish for better nursing ed than I hear about here. :)

Esme12, ASN, BSN, RN · Jan 25, 2015

Risk for decreased cardiac output and Risk for injury. I can't come up with a 3rd for the life of me.
Here is ALL the pt info I have written on my pt research sheet. I wish I had more but I did exactly as my instructor asked which turns out to not be enough.
86 yr old female; Self care
Current dx: nose bleed, rapid atrial fibrillation
PMH: stroke, bilateral cataracts, atrial fibrillation/flutter, hypertenstion, diabetes, hypercholesterolemia, osteoarthritis, lymphedema, breast cancer, colon cancer
PSH: catract sx, colectomy, partial thyroidectomy, carotid endarterectomy, hysterectomy, joint replacement, R. mastectomy, R hand ORIF due to fx
Social hx: lives with family, no illicit drugs, tobacco or alcohol abuse
Labs: RBC (4.51) Hgb (13.3) Hct (40.1) WBC (5.9) Lymphs (39.9) PTT (112.8) PT (11.3) INR (1.0) Glu (131 H) BUN (13) Creat (0.9) eGFR (74) Na (139) K (3.6) Cl (104) CO2 (28) Mg (1.6 L) Ca (9.2) CK-MB (0.6) Troponin I (
Vital Signs 8am: T: 97.6 BP 153/67 Resp: 20 SPO2: 94 on room air Pulse: 70 Pain: 7/10 (L shoulder from old fx)
Vital Signs 11am: T: 97.2 BP 121/56 Resp: 20 SPO2: 97 on room air Pulse: 68 Pain: 7/10 (L shoulder from old fx)
Diet: Cardiac soft
Meds: Insulin Lispro Humalog, Pantoprazole (protonix), Pravastatin Sodium (pravachol), Saxagliptin HCL (Betapace), Diltiazem (Cardizem) Drip, Robitussin, Heparin Sodium Drip, Morphine Sulfate

Lets start back at the beginning.....What semester are you? What care plan resources do you use?

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.

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 from our Daytonite

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.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."
"Related to" means "caused by," not something else.