Care plan and nursing process

Esme12, ASN, BSN, RN · Nov 13, 2013

what do you need to know?

To start........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/care map: 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)

Ok real life application paraphrased from our Beloved Daytonite.....

You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "What's wrong?" You're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it..............a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated.

What you have just done is.......

Step #1 of the nursing process--performed an assessment. You determine that you have a flat tire.

You have just done.....

Step #2 of the nursing process--made a diagnosis. The little squirrel starts running like crazy in the wheel up in your brain. "What do i do?" You are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. .......Good thing you took that class in how to do simple maintenance and repairs on a car!

You have just done.....

Step #3 of the nursing process--planning (developed a goal and intervention). You get the jack and spare tire out of the trunk, roll up your sleeves and get to work.

You have just done.....

Step #4 of the nursing process--implementation of the plan. After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive....... Good....... Everything seems fine. The spare tire seems to be ok and off you go and on your way. You have just done

Step #5 of the nursing process--evaluation (determined if your goal was met).

Does this make more sense? Can you relate to that? That's about as simple as the nursing process can be simplified to... BUT........ you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.

critical thinking involves knowing:

the proper sequence of steps in the nursing process
the normal anatomy and physiology of the human body
how the normal anatomy and physiology are changed by the medical and disease process that are going on
the normal medical treatment that the doctor(s) are likely to order to treat the medical and disease process going on
the nursing interventions that you have learned for the things that support the medical and disease process that is going on
making the connection (this is the critical thinking part) between the disease, the treatment and the nursing interventions and where on the sequence of the nursing process you are

So I am sure this is now clear as mud.......questions?

Check out this thread.....by VickiRn https://allnurses.com/nursing-student-assistance/student-resources-nursing-424826.html

kenee23 · Nov 14, 2013

That does help, a lot actually thanks

Esme12, ASN, BSN, RN · Nov 14, 2013

now what else do you need? Give us a scenario and we can show you what to look for.....

nurseprnRN, BSN, RN · Nov 14, 2013

See, you are falling into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

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. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.)Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.

Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. It would probably have something to do with no increase in pain due to decreased circulation, or perhaps no increase in tissue injury, you might also consider some of the educational components, so one of your outcomes might be that the patient describes…, so you understand that he knows more about his disease.

I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on page 475, you will find "tissue perfusion, peripheral, ineffective." This is followed by the lay definition of what circulation status is, major interventions for arterial insufficiency and venous insufficiency, and a long list of suggested and optional interventions from which to choose. It is important to realize that you can just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon.

It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.