Care plan / nursing diagnosis question.

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I did my first assessment on my clinical PT today in a LTC facility. My very first cinical day on the unit! I have to state five problems I have identified based on info from the assessment, interview and chart. From these five problems, I will eventually identify five nursing diagnoses.

I noticed today that my patient has very long, unmaintained artificial nails, two of which have broken off at the quick. The nails are at least 1.25-1.5 cm past the end of the finger and the artificial product hasn't been maintained in months.

Is this a legitimate problem for me to be concerned about on a care plan? Would Self Care Deficit be a fitting nursing diagnosis? I feel like this diagnosis would fit for a patient with uncared for natural nails, but since her nails have a product on them she may believe there is nothing she needs to do about it.

I hope this isn't too confusing!

Thanks in advance for any insight :)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

After your entire assessment.....this is the only problem? Are badly maintained nails a wound? I would say no. Are the poor hygiene? Self neglect? reflect hopelessness? maybe. Self care deficit? maybe. Look at the taxonomy/defining characteristics does she fit them?

It is necessary to have a good care plan book. I use Aclkey. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

What care plan book do you have?

Care plans are all about the assessment.....of the patient. The is not enough information here for us to help. Tell me about your patient, What is your assessment? What do they NEED? What is their main complaint? What are their co-morbidities? How old is this patient? What is their base line? What meds are they on?

YOU MUST have a good care plan book with the NANDA diagnosis and it defining characteristics.

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

  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.

THese sheet may help you out.....daytonite made them (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

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? ? What is your assessment......What does this tell me about the patient?

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Holy cow... I just had a long reply typed in and my internet froze and I lost it! I'm going to try to retype it all in.

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Overall my patient is stable and requires very little assistance from staff.

I've identified other problems as well but I was wondering if the extra long nails were a a legitimate thing for me to be concerned about from a nursing diagnosis stand point. We're not at the point where we're choosing nursing diagnoses... just problems we saw today. I wanted to make sure this problem was something that would correlate to a nursing diagnosis later. My instructor said that it didn't need to be the five worst problems the patient has, just five that we saw with the thought towards the fact that a nursing diagnosis would follow later.

Today was our very first interaction with our patients and the first assessment data we collected. Unfortunately, my patient became irritable and requested that I not finish my assessment.

As for books, I have the one you mentioned as well as Nurse's Pocket Guide, Diagnoses, Prioritized Interventions and Rationales by Downges, Moorhouse and Murr and the current NANDA book.

I'm familiar with the ADPIE process, but as I stated, we're not there yet in our care plans as of today.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Holy cow... I just had a long reply typed in and my internet froze and I lost it! I'm going to try to retype it all in.
LOL been there...sometime if you reboot the page it will save content.

The nails could be a sign that she used to care and is now doesn't....why? Is she depressed? Has she become confused? They can be a source of infection to the nails. Does she pick and scratch herself?

I would wonder why she had them once and why has that changed. So yes they can be counted but to the reason as to why is what will eventually be important.

Is she depressed? Have a sense of hopelessness? Yes it's self care neglect/ self care deficit. poor hygiene Disturbed Body image her agitation due to...Defensive Coping, Ineffective Coping All a process to adult failure to thrive. Does she show any Readiness for enhanced Self-Care

See where I am going with this?

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YES! Thanks for your responses!

I know in the scheme of things with older patients this is a pretty minor thing compared to other problems they may have. I've been a manicurist for many years so her super long, unkept nails jumped right out at me!

I'm not sure if she scratches herself with them as I wasn't able to complete the skin assessment. She was fully dressed with a long sleeved shirt and sweater on and wasn't receptive to me moving anything around because she was cold. Once I was finished with her BP she was pretty much done with me. :/

The nails appeared clean to my naked eye, but I know they can harbor lots of undesirable microbes. I know I have to keep my nails short, clean and unpolished for school, so...

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

It is not about the artificial nails per say...but it's about why has she stopped caring.

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I'm also concerned about infection-- those nasty nails are impossible to really keep clean. Suppose she toilets and gets some perineal or fecal scunge (technical term there)(do NOT put that in your schoolwork :twocents:) in them. Then where else do those hands go? Eyes? Food? Some other patient? Yeccchhh.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I'm also concerned about infection-- those nasty nails are impossible to really keep clean. Suppose she toilets and gets some perineal or fecal scunge (technical term there)(do NOT put that in your schoolwork :twocents:) in them. Then where else do those hands go? Eyes? Food? Some other patient? Yeccchhh.
Yuck....:poop:
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Specializes in being a Credible Source.
Yeccchhh
Yuck....:poop:
I believe the formal term is, "blech."

RIP Don Martin (Mad Magazine)

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... and the usual band of idiots. I LOVED Mad and would kill to have all my collection back, but my mother threw them away. ::sigh:: Wonder what they'd do c Nurse Jackie?

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