care plan

[busy-bee]

Today my intent was to put altered nutritional status as the nursing diagnosis related to a patients low albumin level. Suggestion was to put...."low albumin" as the care plan since this was the problem. Low albumin is not an approved nursing diagnosis. In this facility every order, there is a care plan, that is for labs draws, xrays, everything...not one order should not have a care plan. I am a bit confused. This is a nursing home, and all the other places I have worked upper management took care of the careplans. I don't object to doing them....just need a bit of help. I thought altered nurtritional status....was much more appropriate than low albumin....what do you think...or do you have better nursing diagnosis. The order I received was "full dietary evaluation related to low albumin level". Help....how about nutrition, imbalance. :bowingpur

[sundowners2]

Here's my take on it. And BTW care plans can be very program-specific (or even instructor-specific), so, whether my way is right or not, you need to learn what your instructor wants so you can pass! =)

I think you're asking if "Altered Nutritional Status: Less than Body Requirements related to low albumin" is a good Nsg Dx. The first part (Altered Nut.) may be right, but the albumin part needs to change. The "related to" segment of the Nsg Dx needs to be the CAUSE of your Nsg Dx. As it is, your Dx says this, "My patients nutritional status is altered, and it is due to his low albumin value." Low albumin is not the CAUSE of poor nutrition; it is the EVIDENCE of poor nutrition. Therefore, it should go under the "as EVIDENCEd by" section.

I would put it like this, "Altered Nutritional Status related to ____ ("put WHY the nut. status is bad here")___ as evidenced by low albumin. Does that make sense? You can't put "Low Albumin" as the first part of the Dx, bc it's not NANDA. You can't put it in the r/t part bc it's not the cause. So it fits in the AEB section because it's a piece of evidence that poor nutrition is actually going on!

Side note: SOME institutions will allow you to include a medical Dx in a "secondary to" section of your Nsg Dx. e.g., "Altered Nut. Status r/t cognitive impairment (or something like that) aeb low albumin SECONDARY TO ___ (a medical Dx like CVA or something)______.

Hope this helps! Good luck with your CP! =)

[sundowners2]

... Are you doing this for work or school? Sounds like you're doing it at work now that I re-read your post. The same general Nsg careplan concepts should apply though.