Care Plan

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I Am Currently In Term 1 And I Have To Do My First Clinical Care Plan...my Pt's Chief Complaint Is Upper Abdominal Pain With Nausea And Vomitting. He Has A H/o Dm, Htn, And Psychiatric Disorder. My Question Is That Am I To List Only The Chief Complaint Being That I Can Not Do Anything About The Dm, Or The Psychiatric Disorder...also His Vitals Are In Normal Range, So I Cant Use That Either...i Thought It Would Be Easier If I Would Have Chosen A Pt With Minor Problems...now It Looks Like I Dont Have Enough Wrong With My Pt To Get A Complete Care Plan Done. Im Stuck On The Nursing Diagnosis Portion. Can Someone Please Help!!!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

You have two very good items to care plan on:

  • abdominal pain (Acute Pain)
  • nausea and vomiting (Deficient Fluid Volume)

Which do you want to proceed with?

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Hi, I am new to this site. I am a nursing student and I am in clinicals. It is very nerve racking sometimes to do these care plans. I need help on mine so any suggestions would be helpful. I had a patient that was admitted to the hospital with cellulitis ble, chf, and iddm. my instructor said they were all primary diagnoses. I am just stuck on the nursing diagnosis, and going from there. Please help me if you can..........thanks.

jen39452:lol2:

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Specializes in med/surg, telemetry, IV therapy, mgmt.
hi, i am new to this site. i am a nursing student and i am in clinicals. it is very nerve racking sometimes to do these care plans. i need help on mine so any suggestions would be helpful. i had a patient that was admitted to the hospital with cellulitis ble, chf, and iddm. my instructor said they were all primary diagnoses. i am just stuck on the nursing diagnosis, and going from there. please help me if you can..........thanks.

jen39452:lol2:

diagnosing is done based upon the nursing process because it is a problem solving activity. here is an analogy of how the nursing process works:

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).

another analogy that works well to explain how diagnosing works is to think about how a police detective works a crime. they follow a process very similar to the nursing process in bringing the killer to justice. lets say someone is found dead. a detective investigates and finds all kinds of evidence of what occurred (assessment). he analyzes this data, makes some decisions about it and decides that the killing was deliberate--it was murder (diagnosis).

the same is true of this care plan of yours that you are attempting to write for a patient who has cellulitis of both legs, chf, and iddm. you need to first do some assessment and investigation of these diseases. what symptoms of them does this patient have? some symptoms are present because the doctor treats symptoms. so, do we. medical diseases are diagnosed based upon the symptoms the patient has (evidence of the medical problem). nursing diagnoses are also based upon the symptoms (evidence of the nursing problem) that the patient has. every nursing diagnosis, just like every medical diagnosis, has a set of signs and symptoms. how do you know what these are? you need a nursing diagnosis reference to help you. there are currently 188 nursing diagnoses and they are not the same as medical diagnoses. here's where you can find this information:

for information on writing care plans see:

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