Care Plan Help!

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We are happy to help but we need to know what you think first.

Care plans are all about the assessment...of the patient. 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. 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 from our Daytonite

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.

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.

I use both. While Ackley is the best book, IMHO, it is incomplete. My NANDA is outdated slightly but a new one is coming out soon.

As far as why they don't recommend it. I have no idea. I think GrnTea is on the right track.

nursing diagnosis for a first time mother who gave birth at 40.4 weeks. She had a healthy baby boy. I need to come up with a nursing diagnosis for attachment, emotional assessment, educational needs, and postpartum risk factors.

Was this a vag birth? Did she have an episiotomy? Think about the cord care. Think about episiotomy care if she has one or suture line care if she is a section. Care of the circumcision or care of an uncircumcised member if the baby is a boy. She may be breast feeding like champ right now but in a couple of days she may need resources to deal with dry cracked nipples. She may be on tha tpost partum high...she will come back to earth. What resources does she have at home? Is Dad involved? Does she know when to call the MD for baby? When to resume sexual relations after delivery? What does she look for? What to do with increased bleeding?

These are all involved on post partum care.

You will never go wrong if you follow the nursing process in writing a care plan. You will only falter in what you lack in knowledge to contribute to the assignment or a lack of where to find the knowledge. The steps of the nursing process as it pertains to care planning are:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)
   

Everything for this care plan rests upon the assessment that you did. your assessment activities include the following, some of which you already did at the hospital:

• a physical assessment of the patient
  
• assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
  
• data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
  
• knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
  

Always keep in mind that in doing assessment it is important that you know what a normal response is supposed to be.....the purpose of assessment when you are care planning is to look for abnormal responses because these are clues (evidence) that a nursing problem exists. Assessment includes looking up pathophysiology, signs and symptoms and medical treatment for any medical conditions that exist. You are only going to know this by knowing what is normal about the process of labor and birth. much of that information should be in your ob textbook.

Think....close your eyes for a second and try to visualize a front seat view of a 7-pound baby coming through the birth canal. What's happening to those tissues in that mother's body! while birthing may be a "normal" process (right!) all that stretching and tearing of those tissues is not! those are injured tissues. What do you know about the pathophysiology of cell and tissue injury? it sets off the inflammatory response. you are not necessarily going to see the resulting signs and symptoms (redness, heat, swelling, pain) because these tissues are deep in the body, but i guarantee they are occurring..... think about the effect this has on the mother's body and surrounding organ structures.

From our Daytonite (rip)

there are also complications of birthing and any procedures that were done to assist the birth that need to be taken into consideration:

• infection due to
  
  • episiotomy
    
  • multiple lady partsl examinations
    
  • labor lasting more than 24 hours
    
  • prolonged time between rupture of membranes and birth
    
  • manual extraction of the placenta by the doctor
    
  • diabetes
    
  • urinary catheterization
    

  [*]pain of the lady partsl tissues

  [*]bladder distension or inability to urinate

  [*]infection in the uterus

  [*]hemorrhoids occur during the pushing of labor

  [*]hemorrhage risk

  • if this is mom's 6th or more child
    
  • prolonged labor
    
  • retained placenta
    
  • induced labor
    
  • if tocolytics were given to stop contractions
    
  • c-section
    
  • forceps delivery or vacuum extraction of the baby
    

here are possible nursing problems (which you would need to turn into nursing diagnoses) that you would determine from abnormal assessment information that you had gathered:

1. women experience afterpains, perineal trauma, their breasts are often engorged with milk and many have hemorrhoids. was there an order for tylenol or motrin?
   
2. if you had gone through 10 or 20 hours of labor how would you be feeling after it was all over? tired, perhaps? drained of energy? need some sleep and rest? hungry? thirsty? need some fluid replacement?
   
3. is the mother breastfeeding? there are 3 nursing diagnoses for breastfeeding: effective, ineffective and interrupted breastfeeding the baby can also have this diagnosis with its own nursing interventions.
   
4. when the baby comes through the lady partsl canal the bladder suffers a temporary loss of sensation for a period of time and there is also a decreased muscle tone to the bladder. this can result in urinating problems.
   
5. some mothers experience orthostatic hypotension as a result of vertigo after childbirth sometimes because of blood loss or dehydration. they could fall and injure themselves.
   
6. many new mothers need teaching regarding care of their episiotomies, prevention of complications and their own health maintenance. some need complete information about baby care, the baby's needs and their normal behaviors.
   

for the baby:

Think about what you know about the assessment findings of a normal newborn compared to an adult. what's different? for one thing newborns can't regulate their body temperature which is why we don't leave them exposed to the room atmosphere for very long with just a diaper covering them......ineffective thermoregulation r/t immature compensation for changes in environmental temperature.

Some newborns just have a few difficulties with excessive secretions in the respiratory track (the big hint here is that the nurses will keep a bulb syringe nearby the baby) so ineffective airway clearance can be used. they also have a stump from the umbilical cord hanging off their future belly button. do you? are they treating this cord stump? if it's inflamed or there are umbilical cord problems there is risk for infection, so you can use risk for infection r/t break in skin integrity at umbilical cord site .

if the baby is a male and has been circumcised that is another reason for a risk of infection. is this baby breastfeeding? if so, use effective breastfeeding. and, some babies just don't start feeding well at first by breast or bottle--it happens. these kids are imbalanced nutrition: less than body requirements r/t poor infant feeding behaviors.

if the baby is under the bililight for hyperbilirubinemia the nursing diagnosis to use is risk for injury r/t phototherapy