a couple quick, general questions about care plans

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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!

Specializes in ICU/CCU.

Make sure you understand the rationale, though. It'll help you soooo much more down the road. The lessons learned with the nursing diagnoses are great ones. Don't make the mistake most of us make and take them for granted. Easier said than done.

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Specializes in Nephrology, Cardiology, ER, ICU.

Let me move this to the nursing student assistance forum.

Good luck.

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Specializes in assisted living.

Thanks so much everyone!!! Everything I read on this site is so helpful! Can't wait to get my bleeding red care plan back :) I have learned so much by doing this 1st care plan!

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We are NOT allowed to include a medical diagnosis in our care plans. I really struggled with that when writing a care plan for a patient with chronic pain R/T end stage breast cancer. I finally ended up writing Chronic pain R/T medical condition but I felt that was too vague.

Also, we always have to have an AEB unless its a risk diagnosis, as several others have said.

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Hi nep1980

I have 2 careplan books that I don't like that much. Can you tell me the complete name or isbn number for the Davis careplan you are using. I tried looking it up just under "Davis" and was getting a bunch of stuff.

Thanks a bunch

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Read your NANDA book it explains everything.

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Specializes in Oncology.
We are NOT allowed to include a medical diagnosis in our care plans. I really struggled with that when writing a care plan for a patient with chronic pain R/T end stage breast cancer. I finally ended up writing Chronic pain R/T medical condition but I felt that was too vague.

Also, we always have to have an AEB unless its a risk diagnosis, as several others have said.

I would write things like...

Chronic pain r/t tumor progression secondary to cancer AEB statement of pain rating of 7/10, guarding and grimacing upon palpation of breast tissue, and description of pain as "aching, intense, constant"

Your "related to" should be the underlying pathophysiology/cause. You can put the origin of this cause (the medical condition) as secondary. This was hard for me to grasp at first, but then after I really got it, everything clicked for me.

Also, I have Carpenito's care plan book and I love it. I have Pagana's lab book for looking up out of whack labs. Personally, though, I think care plan books can do more harm than good if you are using them more than your own critical thinking skills! I would typically use mine simply to check that my diagnosis was a real NANDA diagnosis and that my criteria fit, otherwise I would try to do it by myself.

Another thing - Isn't Risk for Aspiration a higher priority than, say, Anxiety? Just one example of how "Risk" can take higher priority. Remember your ABC's and Maslow's hierarchy when you prioritize nursing diagnoses and you should be fine.

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Specializes in Critical Care.
We are NOT allowed to include a medical diagnosis in our care plans. I really struggled with that when writing a care plan for a patient with chronic pain R/T end stage breast cancer. I finally ended up writing Chronic pain R/T medical condition but I felt that was too vague.

Also, we always have to have an AEB unless its a risk diagnosis, as several others have said.

Says who?

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Says who?

Our instructors, who else?

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Says who?

says NANDA

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Specializes in Critical Care.
Our instructors, who else?

says NANDA

How did we come to believe that either of these groups are authorities regarding what is best for nursing practice?

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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!

mine was optional but we put R/T = related to ?

no nursing diagnosis in the objective data there should be another place for that

objective data should only be used for FACTS due to test results like vital signs ect.......

you could put in the nursing diagnosis : at risk for fractures R/T bone demineralization or osteoporosis

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