Care Plan

Daytonite, BSN, RN · Jan 29, 2008

hi, rn1daysoon, and welcome to allnurses! :welcome:

i don't know if fluid volume overload is your patient's problem. in the nanda taxonomy, which you should be using to help you diagnose, edema is also a symptom of a decreased cardiac output, impaired oral mucus membrane, and ineffective tissue perfusion (peripheral).

to get to your patient's problem you must follow the steps of the nursing process.

assessment (collect data from medical record and by doing a physical assessment of the patient)
nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

to start off you should be spending a good deal of time on step #1, the assessment. you need to develop for step #2 a list of abnormal assessment data. to do that you need to go over what you learned during your physical exam, interview of the patient and what you learned from your examination of the patient's medical record. you need to ferret out the non-normal information. those non-normal information items are actually symptoms that form the entire foundation of everything that becomes your care plan. a symptom is an objective observation you or someone else has made or a subjective perception of the patient. in addition, you need to look up information about the patient's medical diagnoses. in this case hyponatremia, hypokalemia and i'm going to go out on a limb and suggest coronary artery disease because that is probably why the patient had the cabg. you need to look up the typical signs and symptoms of these conditions to see if you happened to miss any of them in doing your assessment of the patient. if you did happen to miss any of them, now is the time to add them to the symptom list that you are creating for your care plan. it just so happens that i posted the symptoms of hyponatremia and hypokalemia on this thread the other day:

https://allnurses.com/forums/f205/major-electrolytes-277734.html

you also need to look up information about the surgery and post-op recovery for a cabg. this is a major procedure. where was the donor vein harvested from? the lower leg? is this the leg that is involved in the edema? is only one leg swollen? or both? is there congestive heart failure going on here? complications of cabg include:

cardiac arrhythmias
hypertension/hypotension
cardiac tamponade
thromboembolism
hemorrhage
postpericardiotomy syndrome
myocardial infarction
stroke
postop depression or emotional instability
pulmonary embolism
decreased renal function
infection

all this preliminary work must be done before even getting around to determining what the patient's problem and nursing diagnoses are. you need to have as complete a list of patient symptoms by the time you are ready to determine the patient's problem as you can. that list is what determines the direction taken by the remainder of the care plan.

the care plan is nothing more than the documentation of your problem solving effort. we problem solve every day of our lives. let me give you a simple every day example of how we problem solve just the very same way we use the nursing process and care planning:

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).

what is different about care planning is that nursing gave the process a name and some very specific rules to follow. not only that, but instead of one symptom to deal with, we usually have to juggle a handful of them (that's all the symptoms on that symptom list i'm harping to you about). but if you notice one thing about the flat tire scenario, all the effort went into assessing and taking care of the flat tire, not the "diagnosis" of the flat tire. you want to do the same with care plans.

now, once you have the complete list of symptoms and you are satisfied with it you can move on to step #2. for this you really need some sort of nursing diagnosis reference. if your school uses nanda then you need a care plan book or a nursing diagnosis book that has the nanda taxonomy in it. i happen to use nanda-i nursing diagnoses: definitions & classification 2007-2008 which contains, very simply, the current 188 nursing diagnoses, their definitions (these are the real problem statements), defining characteristics (we know them as symptoms) and related factors (the causes that underlie the reasons the symptoms occurred). some schools use their own versions of nursing diagnoses. that's ok. you will still follow the steps of the nursing process. important concept: every nursing diagnosis has a set of symptoms called defining characteristics. in order to put a nursing diagnosis on someone you need to make sure that the patient has at least one if not more than one of those defining characteristics (symptoms). doctors don't diagnose anyone with any disease until they've completed their assessment and reviewed their symptoms. we nurses shouldn't be doing it any differently. we have the nanda criteria to do help us do our diagnosing. in addition, you should also read the definition of the diagnosis to assure that it is indeed the patient's problem. the nursing diagnosis (ex: deficient fluid volume) as you know it is only a label and a shortened version of the definition. it often doesn't do justice to the definition. it is very possible to assign a nursing diagnosis by these labels and be totally wrong if you haven't been careful about verifying that the patient has defining characteristics of that diagnosis and the problem fits his circumstances. don't get hung up on this diagnosis business. the real heart of your care plan is that list of symptoms.

step #3 is a where you are developing goals and interventions for the symptoms on that list. those you will find in your textbooks, care plan books and other various places. everything in this step is all about the patient symptoms. forget the nursing diagnosis at this point. they're academic. for writing goals see post #157 on https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html

if you still need help with this, ask. however, i can't help you without knowing more about the patient's symptoms.