Concept map help

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What semester are you? Do you have care plan book? I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition.

You are making a common mistake which is picking the diagnosis and retro fitting the patient into it.......when you should take what the patient needs and apply a name to it.

Care plan/maps are all about patient assessment the whole patient. ....is this a real, patient? What is your assessment? What do they need? Have they had any procedures? What brought them to the hospital? How long have they been hospitalized? What are their vitals signs? What is their main complaint?

Simply put.......Care plans are the recipe card on how to care for someone....logically, rationally. They tell you what is important for any particular patient....and what needs to be looked at, treated, considered first. Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future

Care plans as a nurse is a standard recipe card .....you already "know" how to bloom yeast.....as a student you look up, include the how to, and "learn" how to bloom the yeast so you can remember the how to for the future.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

ADPIE

1. 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)
   
2. 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)
   
3. Planning (write measurable goals/outcomes and nursing interventions)
   
4. Implementation (initiate the care plan)
   
5. Evaluation (determine if goals/outcomes have been met)
   

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

These sheets may help you out.....daytonite made them (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

risk diagnoses don't have "evidenced by" but the have risk factors.......NANDA I describes risk for falls as....

An Increased susceptibility to falling that may cause physical harm

[h=4]Risk Factors (Intrinsic and Extrinsic)[/h]Adults: Age 65 or older; history of falls; fear of falling; living alone; lower limb prosthesis; use of assistive devices (e.g., walker, cane); wheelchair use

Children: Less than 2 years of age; bed located near window; lack of automobile restraints; lack of gate on stairs; lack of window guard; lack of parental supervision; male gender when less than 1 year of age; unattended infant on elevated surface (e.g., bed/changing table)

Cognitive: Diminished mental status

Environment: Cluttered environment; dimly lit room; no antislip material in bath; no antislip material in shower; restraints; throw rugs; unfamiliar room; weather conditions (e.g., wet floors, ice)

Medications: Angiotensin-converting enzyme (ACE) inhibitors; alcohol use; antianxiety agents; antihypertensive agents; diuretics; hypnotics; narcotics/opiates; tranquilizers; tricyclic antidepressants

Physiological: Anemias; arthritis; diarrhea; decreased lower extremity strength; difficulty with gait; faintness when extending neck; foot problems; hearing difficulties; impaired balance; impaired physical mobility; incontinence; neoplasms (i.e., fatigue; limited mobility); neuropathy; orthostatic hypotension; postoperative conditions; postprandial blood sugar changes; presence of acute illness; proprioceptive deficits; sleeplessness; urgency; vascular disease; visual difficulties

So which of these apply to your patient?

Since they already fell.....was the patient injured? Have any abrasions/bruising? What other complaints/issues does this patient have? How does the weakness relate to the UTI which could have contributed to her fall?