Care Plans ... NO Med Surg Text.

Esme12, ASN, BSN, RN · Dec 8, 2012

I know I had talked about this before.....what is the patient ASSESSMENT. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? Again........TELL ME ABOUT YOUR PATIENT...:) what care plan book do you use.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis. Right.......?...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)

What was the assessment......had she ever experienced a prolonged period of hypotension? Is this patient in Septic Shock. What is ARF and what are the causes? Why is this patient anemic? Could her renal failure be more of a chronic issue from her diabetes?? What are the lab work results?

Acute renal failure...... is a rapid loss of kidney function. Its causes are numerous and include severe low blood volume/hypotension from any cause, exposure to substances harmful to the kidney, and obstruction of the urinary tract. AKI is diagnosed on the basis of characteristic laboratory findings, such as elevated blood urea nitrogen and creatinine, or inability of the kidneys to produce sufficient amounts of urine. AKI may lead to a number of complications, including metabolic acidosis, high potassium levels, uremia, changes in body fluid balance, and effects to other organ systems. http://www.mayoclinic.com/health/kidney-failure/DS00280/DSECTION=causes http://www.kidneyatlas.org/book1/adk1_08.pdf

brillohead, ADN, RN · Dec 10, 2012

All kinds of older-edition med-surg textbooks, careplan books, NANDA books, etc., are available at Better World Books for dirt-cheap prices, shipping included, such as:

Manual of Medical-Surgical Nursing Care -- $3.48

Medical-Surgical Nursing: Medical-Surgical Nursing -- $3.48

Assessment and Management of Clinical Problems - 2-Volume Set [With CDROM]

Medical-Surgical Nursing -- $3.48

Critical Thinking for Collaborative Care - 2-Volume Set

Nursing Care Plans and Documentation -- 3.48

Nursing Diagnoses and Collaborative Problems

nurseprnRN, BSN, RN · Dec 15, 2012

Assessment and monitoring are not interventions. And be sure your plan says that you were not able to personally assess this patient for nursing interventions, so this is completely hypothetical because nursing diagnoses are NOT due to medical diagnoses. Your faculty should understand that. (did you see any nursing assessments in the chart while you were reviewing it? YOu could have at least used those to formulate your nursing dx)

StudentOfHealing · Dec 15, 2012

Once again, thanks to everyone who helps.

Well I am done with intro to clinical and thankfully ended up with an A! (=

My clinical professor told me assessment is an intervention. She actually said I should always list as a nursing intervention, to assess the patient. So idk. Maybe every professor is different.... I would think assessments lead to the interventions. no?

Shorty11, BSN, RN · Dec 15, 2012

Our instructor taught us that assessment is an intervention also. Yet she stressed that it is really a RE-assessment. She said that initial assessments are not nursing interventions, but we do use re-assessments as interventions in our care plans. We don't call it a re-assessment in the care plan though. I have listed things like "auscultate lung sounds q 8 hrs", "assess for and degree of peripheral edema q 8 hrs", etc. as nursing interventions in my care plans. The rationale was to determine if the patient's specific condition (listed in the intervention) has deteriorated, improved, or remained the same. Then I can use that information from the assessment to determine if (other) interventions have been effective. I can also determine if one of the patient outcomes/goals is close to or has been meet, and/or also come up with a new patient outcome/goal if it has not been meet in the time frame. I can use this information to edit the care plan or create new patient outcomes. Is it incorrect to use assessing as part of my interventions in care plans?? Just honestly asking if I was wrong for using re-assessments as interventions...

nurseprnRN, BSN, RN · Dec 16, 2012

An intervention is an action you to do intervene, and an assessment is an action you do to collect data. Of course data collection and reevaluation is almost always something you'll need to do when developing a nursing plan of care. My beef is with the "careplans" that say nothing more than "continue to monitor" when there's obviously other important interventions that need doing. Monitoring is not an intervention. If you want to put in a monitoring prescription in your plan of care, you are obligated to also prescribe what you'll do (or delegate to someone else since you aren't there 24/7) if X, Y, or Z is found-- "If dependent edema increasing, recheck weight, recheck I&O, recheck resp rate, breath sounds and SpO2, elevate legs, notify physician." "Notify physician" is not the be-all and end-all of that, either. :)

StudentOfHealing · Dec 17, 2012

When I take exams I despise that answer choice!!! "Notify the physician" I ALWAYS want to choose it as my answer. -__-

StudentOfHealing · Dec 17, 2012

I despise it because it seems SO 'comfortable' but it may or not be the answer.

Stoogesfan · Dec 17, 2012

My instructors have advised me that "notify the physician" is almost NEVER the correct choice, that as a nurse there is almost always something we can/should do before that.

nurseprnRN, BSN, RN · Dec 25, 2012

When you take NCLEX, never never never choose the distractor that says something like, "Refer to dietary," "Call social worker," "Notify chaplain," etc. The NCLEX wants to know what you the nurse does, not to see you the nurse turf it off to another discipline. There will always be a nursing intervention they want to see that you know. This may be (and often is) "obtain more information" in some way, either by asking the patient or family member something like "Tell me more about that" or "What did you do about that?" for example.

Sometimes notifying the physician is on the list; if it's part of the list, fine. But it's rarely the only thing you do. Even in an emergency situation, you don't just go to the phone. There's something else you should be doing-- raising (or lowering) the head of the bed, compressing a bleed, bagging, unblocking the Foley, taking VS and giving prns, something that requires nursing knowledge and judgment. NCLEX is to see if you have those qualities enough to be an RN, so that's why they ask.

cnmbfa · Jan 1, 2013

I am SURE your school has a library, and while it may not have the most recent edition of your book it will have soem sort fo med/Surg book. Or RENT ONE--this is fairly cost effective. I cannot, as a faculty member, fathom how you will make it through with n0o bookl. Or, ask the faculty if they have an older edition you can borrow. Please get a book ASAP.