Desperately need help with a care plan tonight!

CT Pixie, BSN, RN · Jan 29, 2009

I'm doing my first care plan for Med Surg I, and I'm having the HARDEST time!! We were only with a patient for about 5 minutes last week, yet we are expected to write a care plan based on what little information we gathered upon assessment. The care plan part isn't that hard...I can do that. It's just that I'm having a hard time coming up with 3 nursing diagnoses with 3 interventions PER diagnosis. It's for a lower GI bleed (diverticulitis). So far the only diagnoses I can come up with are:
-Risk for deficient fluid volume related to diarrhea, fluid and electrolyte loss, nause and vomiting...(I DON'T KNOW WHAT TO SAY FOR "AS EVIDENCED BY" BECAUSE I DIDN'T SEE HER ENOUGH TO DO SO!)
-Acute pain related to intestinal discomfort, diarrhea, and/or constipation (I can't use this because patient reported no pain, only nausea)
-Deficient knowledge of the relationship between diet and diverticular disease as evidenced by patient's request for food not included in her soft diet. (??? is this even acceptable?).
I'm really struggling with this...I usually don't mind doing care plans! But it's really hard when you only saw the person for 5 minutes and never saw their chart! If anyone has any pointers on this I would be forever indebted to you!

"Risk for" nursing dx's don't have AEB;s because its a risk, not actually happening right now so there is no "evidence".

How about:

Diarrhea related to intestinal inflammatory process ABE (fill in the blank)

Risk for Impared Skin Integrity (perianal) related to diarrhea

You could go with deficient knowledge

ShortStackRN · Jan 29, 2009

"Risk for" nursing dx's don't have AEB;s because its a risk, not actually happening right now so there is no "evidence".
How about:
Diarrhea related to intestinal inflammatory process ABE (fill in the blank)
Risk for Impared Skin Integrity (perianal) related to diarrhea
You could go with deficient knowledge

That's exactly what I said to my instructor! But the form from our teacher has a column that says, "Nursing Diagnosis (related to and as evidenced by...). I was taught by my clinical instructor last semester that we didn't do AEB's, but this instructor says we must! It's such a nightmare!! Thank you for the suggestions!! I REALLY appreciate it!

Daytonite, BSN, RN · Jan 30, 2009

nursing diagnoses are based on assessment. assessment not only involves what you observed but what you know about the medical diagnosis. this patient had diverticulitis and gi bleeding. what medications and treatments were ordered? they are clues that can also tell you things about what is going on with the patient. you should also read up on diverticulosis and diverticulitis: http://www.merck.com/mmpe/sec02/ch019/ch019c.html

acute pain related to intestinal discomfort, diarrhea, and/or constipation (i can't use this because patient reported no pain, only nausea)

pain must be due to something injuring tissues. with diverticulitis, the bowel is injured by small diverticulum that become

inflamed

. the cardinal signs of inflammation are (in this order of occurrence) redness, heat, swelling and

pain

. just because you can't see these things happening doesn't mean they aren't going on. this patient's pain is "related to" the inflammation of the bowel caused by the diverticulitis. "

intestinal discomfort

"

is

pain so you can't make it a related factor. "

diarrhea

" and "

constipation

" are not causes of tissue injury that lead to pain--sorry. the evidence of the pain would be patient's statements of pain and your observations of things like the pain making facial grimaces, crying, holding their stomach or guarding it. your nursing diagnostic statement should say

acute pain related to inflammation of the bowel as evidenced by patient's statements of pain.

deficient knowledge of the relationship between diet and diverticular disease as evidenced by patient's request for food not included in her soft diet. (??? is this even acceptable?).

deficient knowledge (specify) must target a subject. "

the relationship between diet and diverticular disease

" is pretty wordy. how about just shortening it to "dietary restrictions" or "diet"? do you have a nursing diagnosis reference? the "related to" part of the diagnostic statement is the etiology, or cause, of the problem and a nursing diagnosis reference will list those for you. how is the "

patient's request for food not included in her soft diet

" causing her knowledge deficit? answer: it isn't. your related factor is way off. people are deficient in knowledge because they are dumb, lack access to the source of information or maybe just don't care to learn. evidence of that is they tell you some bizarre things they were doing to treat their conditions, they follow superstitious practices, they flat out tell you they need to know more, they ask questions or you see them not performing procedures correctly. so, for this patient use

deficient knowledge, dietary restrictions related to lack of knowledge as evidenced by verbalization by patient of a need to have information about types of food she is allowed to eat.

people with diverticulosis specifically need to avoid foods with nuts and small seeds. do you understand why? small seeds get lodged in the diverticula, the diverticula become irritated and inflamed and the next thing you know--full blown attack of diverticulitis follows and the person is in the hospital with fever and abdominal pain.

risk for deficient fluid volume related to diarrhea, fluid and electrolyte loss, nause and vomiting...(i don't know what to say for "as evidenced by" because i didn't see her enough to do so!)

if this patient is having diarrhea i would use the nursing diagnosis of

diarrhea.

the most likely cause of the diarrhea is the antibiotics that the patient is being given--not the diverticulitis.

diarrhea r/t adverse effects of medications aeb __ diarrhea stools per day, abdominal cramping and hyperactive bowel sounds

. the diarrhea is something that is actually happening and you can include a few strategies for some fluid replacement with your interventions for the diarrhea.

CT Pixie, BSN, RN · Jan 30, 2009

That's exactly what I said to my instructor! But the form from our teacher has a column that says, "Nursing Diagnosis (related to and as evidenced by...). I was taught by my clinical instructor last semester that we didn't do AEB's, but this instructor says we must! It's such a nightmare!! Thank you for the suggestions!! I REALLY appreciate it!

Well yes, you can have a column for related to and as evidence by.

Both a "risk for" nursing dx and the ones that aren't risk but actual will both have "related to" because you must show what is causing the nursing dx, but the "risk for" won't have an AEB because it hasn't actually happened.

You have quite a few "actual" nursing dx's that you can work with so you will have an AEB. why not just work on those, and then ask the instuctor to show you an example of how he/she thinks/wants a "risk for" dx to look.

suzy253, RN · Jan 30, 2009

As usual...Daytonite gives great advice!!!

ExtremeRecluse · Jan 31, 2009

We know that you have not performed a complete eval on your patient, so you must fake it. What else does your instructor expect. Vomiting usually brings on dehydration which cause hyperthermia. You did feel the patients skin when you introduced yourself (right). Dehydration is like your worst hangover on top of a good case of influenza. This has got to be causing the patient much anxiety and enability to cope effectively. Diverticulitus is often treated with surgery. He is being evaluated for this so risk for infection. Improvise until you can't think of anymore lies. Lack of knowledge has got to be at the top. These people have probably abused their digestive system for years for this to occur without having a single clue even if it bit them. If I was throwing my cookies all the time I would most likely be dizzy as hell and that lack of coordination brings on a hell of a risk of falling down and going boom. This is where your critical thinking can really shovel you out of a tight spot. What your instructor does not know will not hurt her. She has been there and she wants to see if you can think on your feet.

UM Review RN, ASN, RN · Jan 31, 2009

We know that you have not performed a complete eval on your patient, so you must fake it. What else does your instructor expect. Vomiting usually brings on dehydration which cause hyperthermia. You did feel the patients skin when you introduced yourself (right). Dehydration is like your worst hangover on top of a good case of influenza. This has got to be causing the patient much anxiety and enability to cope effectively. Diverticulitus is often treated with surgery. He is being evaluated for this so risk for infection. Improvise until you can't think of anymore lies. Lack of knowledge has got to be at the top. These people have probably abused their digestive system for years for this to occur without having a single clue even if it bit them. If I was throwing my cookies all the time I would most likely be dizzy as hell and that lack of coordination brings on a hell of a risk of falling down and going boom. This is where your critical thinking can really shovel you out of a tight spot. What your instructor does not know will not hurt her. She has been there and she wants to see if you can think on your feet.

Sorry, I disagree with this advice. Even more, I disagree with the attitude that somehow this person's diverticulitis is caused by bad eating habits. Diverticulitis is not caused by some moral deficit of the patient's any more than diabetes is. True, it can be exacerbated by noncompliance, but you didn't say that the patient was noncompliant.

Your purpose for this exercise is to be able to do a focused assessment in a short period of time. That is what will be expected of you as a nurse once you are in the real world. Care plans teach you to be observant in that way.

Nurses are like detectives. Things that go unnoticed in the normal course of a conversation are really assessment tools for the nurse. It might help you to sit down and write every single thing that the person said to you and everything about how that patient looked during the five minutes you assessed her.

Write everything down that you remember about the patient: was her skin pink or pale (pale white is usually the color of anemia), was the skin taut and shiny or was it flaccid (slack, flaccid skin is a symptom of possible dehydration). Dark circles under the eyes? (a symptom of many things, especially dehydration and sleeplessness). Did she looked rested or worn out? How was her affect? Bubbly and happy, calm or anxious? Was her pulse racing despite being in bed? (GI bleeds can cause enough volume depletion to affect the heart).

The diverticulitis patients I've had sometimes have very pale skin color (clue: possible GI bleed). They complain of feeling worn out from being up all night in the bathroom (clue: multiple diarrhea episodes depleting the patient's energy and preventing adequate rest), some were very fearful of eating many foods due to the unpleasant aftereffects (clue: is the patient's nutritional needs being met?). Sometimes a patient would say that they were having diarrhea but they did not really have diarrhea (clue: lack of knowledge). Most of these clues did not come after an extensive assessment; they were noticeable within seconds of seeing the patient.

You say that you didn't have enough time to gather evidence based on your assessment to do this assignment, and the post quoted above advises you to make something up. Please don't do that. In the nursing world, it's OK to be new, it's OK to admit that you don't know, it's OK to ask for help, it's even preferable for you to take a big hit to the ego rather than let silence and inaction hurt your patient -- but the one thing you must never ever do is lie. Lying about a patient can get your patient killed. Lying about a patient while you are in nursing school could result in your being "weeded out."

One last question: Did you ask your teacher for help with this? Rather than telling yourself that you cannot do this assignment, approach the teacher as though they are willing to help you and expect you to have questions. I would be suspicious of the student who handed in a lackluster paper and who had no questions at all, if I was the teacher.

I hope you do well on this assignment, but if you do not, you will still have learned a lot about what clues to note when you are doing a brief assessment of a person.

ShortStackRN · Feb 6, 2009

Sorry, I disagree with this advice. Even more, I disagree with the attitude that somehow this person's diverticulitis is caused by bad eating habits. Diverticulitis is not caused by some moral deficit of the patient's any more than diabetes is. True, it can be exacerbated by noncompliance, but you didn't say that the patient was noncompliant.
Your purpose for this exercise is to be able to do a focused assessment in a short period of time. That is what will be expected of you as a nurse once you are in the real world. Care plans teach you to be observant in that way.
Nurses are like detectives. Things that go unnoticed in the normal course of a conversation are really assessment tools for the nurse. It might help you to sit down and write every single thing that the person said to you and everything about how that patient looked during the five minutes you assessed her.
Write everything down that you remember about the patient: was her skin pink or pale (pale white is usually the color of anemia), was the skin taut and shiny or was it flaccid (slack, flaccid skin is a symptom of possible dehydration). Dark circles under the eyes? (a symptom of many things, especially dehydration and sleeplessness). Did she looked rested or worn out? How was her affect? Bubbly and happy, calm or anxious? Was her pulse racing despite being in bed? (GI bleeds can cause enough volume depletion to affect the heart).
The diverticulitis patients I've had sometimes have very pale skin color (clue: possible GI bleed). They complain of feeling worn out from being up all night in the bathroom (clue: multiple diarrhea episodes depleting the patient's energy and preventing adequate rest), some were very fearful of eating many foods due to the unpleasant aftereffects (clue: is the patient's nutritional needs being met?). Sometimes a patient would say that they were having diarrhea but they did not really have diarrhea (clue: lack of knowledge). Most of these clues did not come after an extensive assessment; they were noticeable within seconds of seeing the patient.
You say that you didn't have enough time to gather evidence based on your assessment to do this assignment, and the post quoted above advises you to make something up. Please don't do that. In the nursing world, it's OK to be new, it's OK to admit that you don't know, it's OK to ask for help, it's even preferable for you to take a big hit to the ego rather than let silence and inaction hurt your patient -- but the one thing you must never ever do is lie. Lying about a patient can get your patient killed. Lying about a patient while you are in nursing school could result in your being "weeded out."
One last question: Did you ask your teacher for help with this? Rather than telling yourself that you cannot do this assignment, approach the teacher as though they are willing to help you and expect you to have questions. I would be suspicious of the student who handed in a lackluster paper and who had no questions at all, if I was the teacher.
I hope you do well on this assignment, but if you do not, you will still have learned a lot about what clues to note when you are doing a brief assessment of a person.

I believe what I failed to include in my original thread is that I was doing teamleading with an RN that day...so I actually wasn't the one doing the assessment. The whole story is this...I was told during morning report that this particular patient was admitted for GI bleed into ICU..got better...was going to be DC'd but began complaining of migraine headaches so they let her stay. When I went with the nurse to observe her, she let me go ahead and listen to her heart and lungs, and yes, I did assess her skin when I introduced myself. However, she had no complaints whatsoever about anyting involving the GI bleed...in fact there was no longer any occult blood, diarrhea, nothing but nausea which the patient said came and went with pain meds. The nurse told me that she thought she was a drug seeker and that's why she was still there. Whatever...not my place to judge. Either way, the nurse was treating this patient basically for migraines NOT a GI bleed...there was nothing in her chart about the migraines, and barely anything about the GI bleed (except for what they had in ICU and had DCd already). I didn't spend enough time to adequately write a POC without faking it. And I'm so stupid that I wouldn't ask my instructor! I did ask her! She told me to write a care plan as if I were able to do a full assessment and had information on the patient. Basically, write a generic care plan for a lower GI bleed just so she could see if I knew how to actually write a care plan. I did what she asked. I'm actually top of my class and in no danger of being "weeded out"...I was asking for help because I've never been in a situation where I've had to "fake it" but that's what I was told to do. And no...I would never do this in the "real world". I didn't want to do it in the "student world" but I was asked to and I was merely asking for help with the situation. I'm sorry if I gave the wrong impression that I'm trying to fake my way through nursing school, but this is absolutely not the case.

Daytonite, BSN, RN · Feb 6, 2009

that fact that you were teamleading and didn't do the actual assessment has nothing to do with the actual mechanics of writing a care plan as far as i'm concerned. i've been writing care plans for years and there were many times when i was not the primary person collecting the data. it just means that someone else was delegated to do the data collection. there are circumstances when we won't do all phases of an operation. care planning is a problem solving and management function of professional nursing. if it weren't a higher level function, nursing assistants would be writing care plans and supervising patient care. the last time i looked that wasn't happening. your instructor was right and she told you the same thing i told you in the first 2 sentences of my first reply to this thread: "nursing diagnoses are based on assessment. assessment not only involves what you observed but what you know about the medical diagnosis." as long as your data was good, your care plan will be good. when you have garbage in, you will get garbage out. that was not the situation here.

UM Review RN, ASN, RN · Feb 6, 2009

I didn't spend enough time to adequately write a POC without faking it. And I'm so stupid that I wouldn't ask my instructor! I did ask her! She told me to write a care plan as if I were able to do a full assessment and had information on the patient. Basically, write a generic care plan for a lower GI bleed just so she could see if I knew how to actually write a care plan. I did what she asked. I'm actually top of my class and in no danger of being "weeded out"...I was asking for help because I've never been in a situation where I've had to "fake it" but that's what I was told to do. And no...I would never do this in the "real world". I didn't want to do it in the "student world" but I was asked to and I was merely asking for help with the situation. I'm sorry if I gave the wrong impression that I'm trying to fake my way through nursing school, but this is absolutely not the case.

If you are saying that you already turned the care plan in using information that you made up, and that you had your instructor's blessing to do so, then your assignment is complete. No need to justify.

But know this -- in the real world, there will be days when all you really have is about 5 minutes to assess a patient and read the chart. So I'd advise you to hone those assessment skills.

Good luck.