Care Plan Help

Welcome!

What semester are you? Let me start with my usual speech....LOL

Care plans are all about the patient 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.

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.

assessment consists of gathering data about:

• a health history (review of systems) - you've provided more than enough of that
  
• performing a physical exam - you have none and this information is crucial to have
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) you have none and we nurses are pros at adls--its what we do
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this information is needed for the etiologies on your nursing diagnostic statements
  
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what its side effects and potential complications are
  

Now... A nursing diagnosis goes like this.... 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.

Each nursing diagnosis has a definition, defining characteristics (symptoms that you patient has), and related factors (what causes it).

All care plans are based off your assessment. What meds is the patient on? What are the labs exactly? Is she febrile? What does she complain of? What does she NEED right now?

Tell me your assessment.

I am really confused. My patient (73 y.o female) was brought to ER for unresponsiveness. Her labs show high cardiac enzyme levels (troponin & CK-MB) indicating she had a MI. On top of this she has been treating Bronchitis with a Z-pak for a week with no success. Now she has pneumonia. When writing up my care plan which medical diagnosis should I focus on? Which is priority? I want to say pneumonia because its causing respiratory problems from excess mucus and infection which would lead to more problems due to improper oxygenation, however, with a heart attack (She had stents placed) circulation is a problem which could lead to more problems also.

I would greatly appreciate any input!

Thank you!

What are her vital signs? What is her O2 sat? Is she in pain? Is she alert now? What do her lungs sound like? What are her labs?

Ok....now you are falling into the trick bag all students do...picking a diagnosis then fitting the patient into it. What care plan resource do you use?

NANDA describes/defines impaired gas exchange as: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

NOw your patient must have one of the characteristics in the defined characteristics...Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances

If she complains she is unable to expel mucous....then she may have Ineffective Airway Clearance defined as : Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

She must have at least ONE of the following defining characteristics....Absent cough; adventitious breath sounds (rales, crackles, rhonchi, wheezes); changes in respiratory rate and rhythm; cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum; orthopnea; restlessness; wide-eyed

What did her lungs sound like? Describe her cough.

infection is NOT a NANDA diagnosis. A patient can be AT RISK of an infection...but she already has an infection.

Abnormal findings that I assessed were some crackling in the lungs, patient coughing but not productive 100% of the time and complains shes unable to expel mucus, SpO2 in range of 95-98% on room air, temps ranging from 99 F to 104 F since admission, her legs appeared edematous and when I assessed for pitting (1+), she is wearing ted hose. No complaint of pain, but when assessing puncture site in groin for bleeding by palpating surrounding area after cardiac cath she had the evening prior, she winced. Bruising observed on arms from blood draws due to anticoagulant. She had a foley but it was discontinued. She was able to get out of bed and perform ADL's with close supervision.

Looking at this your priority right now is her Fever...is she still febrile when you took care of her?

Lets say she is still febrile. Your concern is her fever (especially if its 104.0). NANDA describes hyperthermia as : Body temperature elevated above normal range.

There are 2 "types of hyperthermia.

1) Elevated body temperature can be either fever (pyrexia) or hyperthermia. Fever: a regulated rise in the core body temperature to 1° to 2° C higher than the client’s normal body temperature as an innate immune response to a perceived threat and is regulated by the hypothalamus.

2) Hyperthermia: an unregulated rise in body temperature that occurs when a client either gains heat through an increase in the body’s heat production or has developed an inability to effectively dissipate heat Hyperthermia is not adaptive and should be treated as a medical emergency.

Your patient must have one of the defining characteristics: Flushed skin; increase in body temperature above normal range; tachycardia; tachypnea; warm to touch; seizures in children

Related to one or more of the following: Anesthesia; decreased perspiration; dehydration; exposure to hot environment; inappropriate clothing; increased metabolic rate; medications; trauma; neurological disorder/injury; strenuous physical activity in hot climates, infection.

My resources for information.... Ackley: Nursing Diagnosis Handbook, 10th Edition and the NANDA resource itself...Nursing Diagnoses 2015-17: Definitions and Classification (NANDA Nursing Diagnoses)