Care Plan Help!

nurseprnRN, BSN, RN · Jan 18, 2014

Not exactly, but you have come to the right place to get straightened out! We can help!

Where is your nursing assessment of his condition? This is all medical diagnoses.

See, 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 (the next one will be 2015-2017), 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 for each of the nursing diagnoses you identify for THIS patient based on your own assessment of his condition and such.

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.

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.

Esme12, ASN, BSN, RN · Jan 19, 2014

I'm trying to create a care plan but have never been taught how to do one. I think I'm over thinking them and making myself crazy. I have a patient with just a sheet of information, not an actual patient to assess and that's frustrating as well.
My patient: 23 year old white male, has respiratory alkalosis, anemia, autism, cerebral palsy, encephalopathy, encopresis, epilepsy, hypernatremia, mental status change, and urinary incontinence. He is non verbal and can ambulate with and without his braces. We are not allowed to do falls because instructor says most facilities have them in place.
I've already competed one care plan on impaired urinary elimination r/t incontinence but I need to more and I was thinking:
Risk for injury r/t epileptic seizures
Impaired verbal communication r/t autism
Am I on the right track?

is there any assessment data like symptoms, vital signs, issues?

Jennie03 · Jan 19, 2014

His temp is normal, his pulse it says is high at 21, his O2 is high at 100, BP is normal, BUN is high and Sodium is high, Creatinine is low, RBC, HgB, and HCT are all low. He has 0 for pain level. I can usually come up with goals and interventions but have trouble coming up with the nursing diagnosis.

Jennie03 · Jan 19, 2014

I wish I would have been able to assess the patient for myself instead of a paper with some facts jotted down on them. I don't feel like I have enough information to make good care plans. I had another to do last week with drug overdose but wasn't told what he overdosed on, depression but not what kind of depression or possible reasons for depression, suicide attempt but not how and possible reasons why. It's frustrating. I could do the same old falls, infection and hypertension but I'm going to see more than that when I get out there and work! Thanks for the help!

Esme12, ASN, BSN, RN · Jan 19, 2014

His heart rate is "high" at 21? Is O2 sat is "high" at 100%? What are the actual lab values?

High BUN and Sodium make me think dehydration....or another metobolic disorder like Addisons

My patient: 23 year old white male, has respiratory alkalosis, anemia, autism, cerebral palsy, encephalopathy, encopresis, epilepsy, hypernatremia, mental status change, and urinary incontinence. He is non verbal and can ambulate with and without his braces. We are not allowed to do falls because instructor says most facilities have them in place.

Why does he have respiratory alkalosis? Do you know what meds he is on? What kind of mental status change?

These are just a few I could think of by looking at what you provided

Bathing Self-Care deficit

Impaired verbal Communication

Bowel Incontinence

Risk for Injury

Impaired physical Mobility

nurseprnRN, BSN, RN · Jan 19, 2014

His temp is normal, his pulse it says is high at 21, his O2 is high at 100, BP is normal, BUN is high and Sodium is high, Creatinine is low, RBC, HgB, and HCT are all low. He has 0 for pain level. I can usually come up with goals and interventions but have trouble coming up with the nursing diagnosis.

Nobody's pulse is high at 21. Pulse oximetry on room air is normal at 95-100% saturation. Your lab values tell me things about his medical condition, but not much at all about his nursing needs.

Again, and this is critical: This is a nursing assignment. Nursing diagnosis is not tied to medical diagnosis.

Do you have the NANDA-I 2012-2014 yet? If you open it randomly and read one nursing diagnosis with its defining characteristics I think you will have an eye-opening moment as to how this works.

For example, here's one nursing diagnosis that I have rarely seen students use but given the patient clientele a lot of students see I think more of them should look further than "the usual" falls, infection, alterations in breathing, and hypertension (PS, hypertension is not a nursing diagnosis) and see if it applies to any of their patients in clinical:

Adult Failure to Thrive:

Definition: Progressive functional deterioration of the physical and cognitive nature. The individuals ability to live with multisystem diseases, cope with ensuing problems, and manage his or her care is remarkably diminished.

Defining characteristics:

altered mood state

anorexia

apathy

cognitive decline (decreased perception, demonstrated difficulty responding to environmental stimuli, demonstrated difficulty with concentration, demonstrated difficulty with decision-making, demonstrated difficulty with judgment, demonstrated difficulty with memory, demonstrated difficulty with reasoning)

consumption of minimal to no food at most meals (e.g., consumes less than 75% of normal requirements)

decrease participation in activities of daily living

decreased social skills

frequent exacerbations of chronic health problems

inadequate nutritional intake

neglect of financial responsibilities

neglect of home environment

physical decline (e.g., fatigue, dehydration, incontinence of bowel and bladder)

reports desire for death

reports loss of interest in pleasurable outlets

self-care deficit

social withdrawal

unintentional weight loss (e.g., 5% in one month, 10% in 6 months)

Related factors: Depression

You will note that none of this is particularly connected to a defined medical diagnosis, even though the medical diagnosis of "depression" is the cause. These are the sorts of things that physicians do not generally assess or diagnose. However, nurses do. This is why we have our own set of nursing diagnoses. Each has defining characteristics, in the same way that the medical diagnosis of "anemia" is defined by specific alterations in the CBC. One or more of the defining characteristics listed above, as assessed by you, justifies your nursing diagnosis of adult failure to thrive.

I specifically chose this is an example for reason. I hope this clarifies you are thinking, and strongly urge you to get this book. It will put you way ahead of your classmates.