critical care plan for CABG post-op 3 days

Esme12, ASN, BSN, RN · Feb 6, 2015

Welcome to Allnurses!

We are happy to help but we need to know what you think first.

What semester are you?

Care plans are all about the patient assessment.

Here is my standard speech.....

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.

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.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

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, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

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 from our Daytonite

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)

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.

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.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

Now tell me about your patient.

lwhatley · Feb 23, 2015

At risk for surgical site infection; At risk for ventilator associated event; Tissue perfusion impaired; fluid and electrolyte imbalance; at risk for urinary catheter associated infection; at risk for bleeding....

nurseprnRN, BSN, RN · Feb 24, 2015

Go confused all dx suggested were rejected that , they only fit med-surg not critical care

What kind of foolishness is that? Do medical diagnoses have geographic boundaries?

Nursing diagnoses have defining characteristics and related (causative) factors. If someone has, say, an ineffective sexuality pattern (I chose that randomly from my NANDA-I 2015-2017, which you should have) that was identified when she was a patient in med/surg, does that mean a nurse in the ICU cannot observe the same defining characteristics and diagnose it there, too?

What did you observe in your critical care patient?

PLEASE see some of the other longer posts about what nursing diagnosis is and is not, how you make a nursing diagnosis, and why we care.

Esme12, ASN, BSN, RN · Feb 26, 2015

I wish they would come back so we could help......

NRKB, MSN, RN · Mar 5, 2015

An infective sexuality pattern? What does that even mean?! One day you identify as female, the next as male? Or your sex life has no pattern to it?

nurseprnRN, BSN, RN · Mar 5, 2015

An infective sexuality pattern? What does that even mean?! One day you identify as female, the next as male? Or your sex life has no pattern to it?

:: tapping foot :: OK, since you clearly don't have the book you are working from a position of deficient knowledge, so I will spell it out for you. NANDA-I 2015-2017, p. 306.

Ineffective (not "infective" :) ) sexuality pattern, Domain 8, Sexuality; Class 2, Sexual function

Definition: Expressions of concern regarding own sexuality

Defining characteristics:

* Alteration in relationship c significant other

* Alteration in sexual activity

* Alteration in sexual behavior

* Change in sexual role

* Difficulty c sexual behavior

* Difficulty c sexual activity

* Value conflict

Related (causative) factors:

* Absence of privacy

* Absence of significant other

* Conflict about sexual orientation

* Conflict about variant practice

* Fear of pregnancy

* Fear of sexually transmitted infection

* Impaired relationship c significant other

* Inadequate role model

* Insufficient knowledge about alternatives related to sexuality

* Skill deficit about alternatives related to sexuality

allnurses Guide · Mar 5, 2015

The concept of "infective" sounds more interesting. :)

Sent from my iPhone.

NRKB, MSN, RN · Mar 5, 2015

Yes, if I had the book i would have looked it up! Ill have to get one when I'm not broke! Sorry I didn't have my glasses on and I'm on my phone. It looked like I typed "ineffective" at the time! Anyways, "nursing school" really needs to be included in that "related to" list. Yikes!

nurseprnRN, BSN, RN · Mar 5, 2015

Yes, if I had the book i would have looked it up! Ill have to get one when I'm not broke! Sorry I didn't have my glasses on and I'm on my phone. It looked like I typed "ineffective" at the time! Anyways, "nursing school" really needs to be included in that "related to" list. Yikes!

Would that be, "Ineffective sexuality pattern as evidenced by alteration in sexual activity due to impaired relationship with significant other"? None of my business, of course, just using the illustration for educational purposes.

My condolences. Been there, done that.