Care plan question


I was hoping that someone could give me some guidance in coming up with a care plan for a brief case study. I don't have really any experience with care plans and I'm a bit lost as to how to proceed. The case study involves a couple in their 60's that has to commute several hours for the husband's hemodialysis 3 times a week (he has chronic kidney disease). They are fed up with the financial and time commitments that the appointments are causing. The husband has been admitted to the hospital for pulmonary edema and has not been following his 1.5L daily fluid restriction at home.

I was thinking of a diagnosis of Ineffective coping related to financial and time commitments of hemodialysis appointments and a second diagnosis of insufficient knowledge regarding chronic kidney failure home care. I was wondering if these fit the situation very well? I'm pretty new to care plans.

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

First, you need to get the NANDA-I 2012-2014, because you cannot make a nursing diagnosis without knowing precisely what defining characteristics, well, define it. I am looking at page 348 in mine, and none of the defining characteristics for the nursing dx of "ineffective coping" are the ones you give. See, even though it might sound good, you can't just make this up. There is also no such nursing diagnosis as "insufficient knowledge," though there is, "deficient knowledge." Your assessment findings might meet its defining characteristics.

For any nursing diagnosis (exception: risk for... diagnoses;special case; look it up) you have to have assessed both at last one related/causative factor and one defining characteristic to make a nursing diagnosis. This is sort of like the physician who cannot make a diagnosis of, say, anemia without getting a CBC and noting its results are diagnostic of anemia.

There are online lists of "NANDA diagnoses," but as we see, without the full reference, you can't just choose one because it sounds good to you. Any diagnostic process relies on defined assessment data.

So. Here's the full scoop. Do NOT be blown away. This is not rocket science, but it is science, and there are these three books that will absolutely save your bacon all the way through the rest of your schooling.

Never fall 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.

In all fairness, we see ample evidence every day that nursing faculty sometimes have a hard time communicating this concept to new nursing students. So my friend Esme and I do our best to reboot you and get you started on the right path. :)

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 should come 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)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

"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 or iPad 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! Wonder where you learned that??? :)

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. Sometimes they're out of date, too-- NANDA-I is reissued and updated q3 years, so if your "handbook" is before 2012, it may be using outdated diagnoses.

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 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 and at least one of the related / caustive factors are present. If so... there's a match. Congratulations! You just made a nursing diagnosis! :anpom: 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. Make sure it's congruent with your patient's wishes-- never forget that any patient can refuse any care or intervention, any time.

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 pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current nursing diagnoses and includes several that have been withdrawn for lack of evidence; you want the most current edition, 2011.

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.

Let this also be your introduction to the idea that just because it wasn't on your bookstore list doesn't mean you can't get it and use it. All of us have supplemented our libraries from the git-go. These three books will give you a real head-start above your classmates who don't have them.


264 Posts

Specializes in ICU.

GrnTea already chimed in and she's the care plan guru around here, so definitely take her advice to heart. I just want to throw in my two cents here. As a disclaimer, I'm also a student so I am no way an expert here. As GrnTea said, you need to look up the dx to see if they actually fit your patient. A diagnosis that addresses their frustration with the dialysis and such-- i.e. deficient knowledge is important. However, my teachers always say you need to address the primary issues and chose priority diagnoses (using S&O data) based off the ABCs, Maslow's or something of that sort. So with that, I think it would be important to add in a diagnosis that addressed the pulmonary edema.. Based off of ABCs, that is a primary need that needs to be addressed. Good luck! Care plans, especially the first one, can seem really scary and impossible, but they're really not too bad. With some sort of diagnosis handbook, like the one GrnTea recommends, you have all the answers right in front of you. You've just got to find them :)

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

Thanks for the plug. :) Just a small clarification: NANDA-I 2012-2014 is not a nursing diagnosis "handbook." It is the only authoritative resource for scientifically-validated nursing diagnoses. Period. Don't let that language scare you into thinking it's some egghead dense thing that will make your eyes cross when you try to make heads or tails of it. It's clear, bullet points, and unambiguous. Trust me. Really.

There are several other "handbooks" out there, but they are not current for the reasons I mentioned. Do not pass Go, go directly to NANDA-I. :)

Thank you very much! your post was incredibly helpful and really clarified a lot of things for me :). I think I'll be telling some of my fellow confused classmates to read what you posted to clarify it for them too. I've got an order into amazon for the books, looking forward to getting them. Wish me luck and thanks again that was great!

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

Good luck, and you will be off to a head start! (And so will your friends.)