Care Plan Help?

nursej22, MSN, RN · Nov 25, 2015

Sorry, but I think that is a bit of a stretch. Your care plan should be based on your patient assessment, not the medical diagnosis. Are the vital signs stable? Any elimination problems? Is there any pain? Is the wound healing? Nutrition status? Any self-deficits? Coping with body image changes?

Without an assessment, one can only guess about nursing diagnosis, these are just a few off the top of my head.

cmar13 · Nov 25, 2015

Vital signs stable, there is pain r/t her incision which I have a diagnosis about, her wound is well approximated but not to the extend they believed it would be at this stage.

Nutrition status is good, no self care deficits and she's well accepting of her new changes, it's something she knew was coming and is positive about it.

I also should add my clinical teacher was the one to tell me risk for infection is my number one diagnosis - that's why I was stuck trying to figure out a possible wording

nursej22, MSN, RN · Nov 25, 2015

I wouldn't think recovering from an infection compromises one's immune system, quite the opposite. Unless perhaps, she was infected with a drug resistant organism.

Perhaps she is at risk related to an invasive line?

cmar13 · Nov 25, 2015

I thought of that.. I was also going to add r/t site for organism invasion secondary to iv site and abdominal incision.. I was just lost as to how to include her previously being septic since my teacher was very vocal that I needed to include it

cmar13 · Nov 25, 2015

She's currently still recieving 3.375mg tazocin iv qid also

Whispera, MSN, RN · Nov 25, 2015

so...it's not a risk...

cmar13 · Nov 25, 2015

she's clear of infection now though, and is just finishing up a course of antibiotics so she technically is infection free now.

I'm equally as confused right now and didn't see it as a risk for diagnosis but since my teacher is insisting I used it I was hoping someone could help me try to make sense of it.

nursej22, MSN, RN · Nov 26, 2015

Perhaps she's at risk for c. diff due to loss of normal gut flora from antibiotics?

Esme12, ASN, BSN, RN · Nov 29, 2015

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.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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

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.

So tell me about your patient.......What do they need? What do they c/o? Did he have a surgical intervention/evacuation of the hematoma? What is your assessment......What does this tell me about the pateint?