Care Plan Help!

AmyRN303, BSN, RN · Mar 28, 2014

Always base your planning on assessment. Remember that readiness diagnoses are valid too...it's not always coming up with something "wrong".

Esme12, ASN, BSN, RN · Mar 28, 2014

Welcome to AN! The largest online nursing community!

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

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.

nurseprnRN, BSN, RN · Mar 28, 2014

Your NANDA-I 2012-2014 has a number of nursing diagnoses which you could make after appropriate assessment that could apply to a normal, experienced nursing mother/baby dyad. Get it. Get it now. It is the only authoritative list of nursing diagnoses with related (causative) factors and defining characteristics. There is no substitute, and that's not just advertising hype, it's the truth. Amazon.com, $29 and free 2-day delivery, or $25 and instant delivery to your Kindle or iPad.

AmyRN303, BSN, RN · Mar 28, 2014

GrnTea, I just posted elsewhere, but I'm wondering why as students we were made to purchase Ackley as opposed to NANDA-1...could it be the formatting of the book? I know Ackley uses NANDA, but it seems to me it would be more useful to have the original. Any thoughts?

nurseprnRN, BSN, RN · Mar 28, 2014

Honestly, I think it may be because your faculty hasn't see it in donkey's years. It is such a better book than it was even 6 years ago-- clearer, infinitely better index, better explanations. The 2009-2011 edition was a real breakthrough. If your faculty suffered through bad nursing diagnosis teaching and learned to rely on essentially canned plans from handbooks, that's why they teach it that way.

Use the real thing. If by any chance anyone questions your language, pull it out and say you were interested in seeing the original source the handbook cites, got the most current edition, and found it useful.

The other books I mentioned will help you a great deal with looking at interventions and outcomes. All three together will really make it possible to see how to plan to deliver or delegate someone's nursing care, which is why you're in school. :)

There is no reason why you can't buy a book just because it's not on the bookstore list. :) I just bought three new ones and I've been out of school for mumblemumble years. :)

AmyRN303, BSN, RN · Mar 28, 2014

I need to update anyway. I just graduated in January, and I'm job searching. I know a lot of facilities have resources, but I like to have my own :)

Esme12, ASN, BSN, RN · Mar 28, 2014

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.

nurseprnRN, BSN, RN · Mar 29, 2014

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.

The next one won't be out for more than a year, probably mid-2015.

:)

AmyRN303, BSN, RN · Mar 29, 2014

Thanks....I googled around and saw that. I'll probably go ahead with the current edition and them purchase the new one when it comes out. Thanks, GrnTea!

grace2971 · Mar 30, 2014

I didn't think of the readiness diagnosis. Thank you:)

Esme12, ASN, BSN, RN · Mar 30, 2014

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.

Well remember you are caring for the Mom and baby.

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.