a couple quick, general questions about care plans

[clearblue3]

Hey! Just a couple quick questions about care plans...Doing my first one. Do you have to "as evidenced by" in your diagnosis or is that optional? My instructor made it sound like that was optional?? or at least that is how I interpreted her comment on that. Also are you supposed to include medical diagnoses in the objective data? ie. can you put osteoporosis or should I put something about bone demineralization? If they don't go in the care plan, then is it just expected that everyone following the care plan has looked over their diagnoses in their chart? Thanks much!

[litchi]

My instructors always made us include AEB or r/t in our diagnosis. We also had a spot for patient information at the very beginning, which is where we would include medical diagnoses/medications/anything relevant to the diagnosis that wasn't part of our assessment.

[nep1980]

you should buy a care plan book, a good book that i like is the davis care plan book but the care plan should be either an actual or at risk for diagnosis. the at risk for never has as evidenced by or it wouldn't be at risk for....but the actual must have as evidenced by so if its actual is would be something like:

impaired skin integrity related to impaired mobility as evidenced by 2 inch pressure ulcer on sacrum.

or risk for infection related to surgical wound.....(but see here there is no as evidenced by, b/c if it was evidenced by something, well then there would be an infection and thus no risk for an infection)

never have a medical diagnosis in a nursing diagnosis, unless it is something like anxiety or something that is both a nursing and a medical diagnosis...... the medical diagnosis go somewhere else on your clinical prep sheets if that is what you mean

[clearblue3]

Thanks! We don't have a spot for the medical diagnoses. Under objective data it says include observations, labs, meds, and client history. Could history mean actual medical diagnoses? I will probably throw it in that section because there isn't any other spot fot it. I have "related to" for all of my diagnoses, but not AEB. I will add that! Thanks for the davis care plan book recommendation. The one we had to buy for fundamentals was not the best and no one likes it. Thanks for the help!

[nep1980]

Thanks! We don't have a spot for the medical diagnoses. Under objective data it says include observations, labs, meds, and client history. Could history mean actual medical diagnoses? I will probably throw it in that section because there isn't any other spot fot it. I have "related to" for all of my diagnoses, but not AEB. I will add that! Thanks for the davis care plan book recommendation. The one we had to buy for fundamentals was not the best and no one likes it. Thanks for the help!

Did they have you buy carpunito??? or something similar to that??? They had us buy that it was HORRIBLE, apparently she is the "guru" of care plans, once I bought the Davis care plan book I got extra hours of sleep, plus it had the labs that would be messed up for my patients with a certain diagnosis and what tests would/should/could/might be done on said patient and whey they would be out or range. I got extra sleep and my instructor accepted my care plans and I was finished handing them into her way before most other students! I still had to do them but I didn't have to hand them in by half way through the semester :heartbeat:heartbeat:heartbeat:heartbeat:heartbeat:yeah::yeah::yeah:

[Quark09]

Your first careplan will likely bleed red once you get it back However, it won't take you too long to see what different instructors are looking for. We always had to include AEB if the ND was not a "Risk for" or the like. If we wrote a medical dx anywhere in the ND we wrote as "secondary to" - like Impaired Skin Integrity r/t immobility secondary to advanced Parkinson's. If we put it in the history they wanted to see assessment data that corroborated/supported the ND, since they wanted to see how it fit in with that specific problem.

[litchi]

Since you're not sure, I'd just include any medical diagnoses as "history of COPD" or whatever in your assessment. That should work. Like Aleah_RN said, once you get your first one back you'll have a good idea of how your instructors want things.

I have the Davis nursing diagnosis book.. it took some getting used to, but it's pretty good. Some people in my clinical group really liked to use this care plan constructor. It's easy, not to mention free. I still like having an actual book, but that's just a personal preference more than anything..

[danegerous, BSN, RN]

The medical diagnosis, unless specifically asked for, shouldn't go on there...However, I'm surprised it's not asked for.

When using Nursing Diagnoses, as stated by the others, there are two types: actual and risks. Actual are always a higher priority. They follow the: "Impaired Tissue Integrity related to [objective data, never medical diagnosis] as evidenced by..." formula. We always had to put three things in the "as evidenced by" section. In this case it would be "...2" deep sacral pressure ulcer, erythema over bony prominences, and 3+ pitting edema."

I just got tired of typing. I hope that little bit helps.

[mtdnk]

The medical diagnosis is not part of a nursing diagnosis. Nursing is the diagnosis and treatment of actual or potential human responses to health problems. The AEB is merely the current symptoms your patient is exhibiting that supports your nursing diagnosis. If the diagnosis is a "risk for" the patient can't have symptoms, right? Then they would actually be having the problem.

[danegerous, BSN, RN]

If the diagnosis is a "risk for" the patient can't have symptoms, right? Then they would actually be having the problem.

For some reason, this took a while to grasp. Not necessarily the concept, but the rationale that Risks were always less of a priority than actual issues. I always thought the risk for infection in a surgical patient, for instance, was a higher priority than altered body image and all that.

Funny enough, these are extremely relevant in actual nursing practice, as they help shape the goals over the time spent in the hospital. On every admission I am required to print out/fill out the nursing diagnoses specific to my patient. Don't take care plans too lightly, they really are extremely helpful. Every once in a while I find myself writing out med cards just to better learn some of the more off-the-wall or not so common meds.

[Quark09]

I always thought the risk for infection in a surgical patient, for instance, was a higher priority than altered body image and all that.

Very true! When I was in school, we had to do three ND for each patient; in the beginning (and with certain instructors) they would only allow one of these to be a "Risk for." However as the semesters progressed, we learned that in some cases (post-op patients, for example) certain "Risk for" diagnoses (as the one mentioned above) were of a higher priority.

As for including a medical dx "secondary to," I think we really only did that first year (CPs were a lot longer too) to help us put all the information together and see how the symptoms, history, risk factors, etc. all worked together. There was an amazing member on here who had the best ND advice (she's since passed away, I just read ). Her posts are still here though; if you search different nursing dx you'll come up with hundreds (if not thousands) of posts. When I was first learning how to set up NDs I'd go through her posts.

[Esme12, ASN, BSN, RN]

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/

A nice resource :)