Desperately Need Help With Care Plans

[Daytonite, BSN, RN]

bld24 said:

I'm having a problem stating a proper nursing diagnosis. This is the only part of the care plan i'm having issues with. For some reason my brain is just not getting this. For instance i have a client this week that has a dehisced wound on her abdomen that is infected. The wound was caused by surgical removal of a portacath secondary to infection.
So i've got the first part of a ndx: impaired skin integrity r/t--- then i go blank on what to write.

Now i know her skin is impaired due to a surgical procedure that was done due to an infection.

Can someone help me with the proper way to write this ndx?

Thanks

The actual writing of the nursing diagnosis statement is based on the correct language, or words to use as well as correctly expressing each part of what the diagnostic statement is supposed to contain. The 3-part nursing diagnosis statement follows this format: pes, where p = problem, e = etiology (or cause), and s = symptoms. By the nanda-i (north american nursing diagnosis association, international) guidelines that means writing the nursing diagnostic statement as:

Tthe nursing diagnosis [problem]--related factor(s) [etiology, or cause]--defining characteristics [symptoms]

Most people are pretty good at putting together a list of the patient's symptoms and usually at picking the nursing diagnosis. The bigger problem is that dog gone "related factor", or etiology, which is where you drew your blank. This part of the process involves some thinking since the words you choose are important--and no medical diagnoses are allowed, usually. You need to take your group of symptoms and ask yourself, "what do they all have in common as the cause of this patient's problem?" the people at nanda-i did a lot of this thinking for nurses over the years because this part of the process has been a real stickler. This is sometimes where nursing care plan books and nursing diagnosis books can help you out since they've already worked up some of these things for you.

Actually, in reading your post, i saw that you had the elements for the r/t part of your diagnostic statement right in front of you, but you weren't seeing them for what they were. Looking at my nanda resource for this diagnosis wasn't a lot of help, for the actual wording to use, that is. However, the good thing about nanda is that they encourage creativity with writing these things. So, let me help you out.

• Nursing diagnosis (problem) = impaired skin integrity
• Related factor (etiology, cause) = open surgical wound on abdomen
• Ddefining characteristics (symptoms) = [this part of the statement is the actual abnormal data assessment items you collected. they will be things such as the description of the wound and character of any drainage, results of any culture and sensitivity done of any exudates. in other words, the definition of this diagnosis is altered epidermis. what are you observing or have found in the medical record of this patient that has led you to the conclusion that she has altered epidermis, keeping in mind that wound dehiscence and infection are what are the underlying cause?]

Put all three elements together and you have your nursing diagnostic statement.

Impaired skin integrity r/t open surgical wound on abdomen aeb

To carry this two more steps farther (for others who are reading this), goals, or outcomes, are based on turning around the problems and symptoms. nursing interventions are developed for each of the defining characteristics, or symptoms, listed under each nursing diagnosis.

[Daytonite, BSN, RN]

In your original post you asked for help with the nursing diagnoses and which ones should be listed (focused upon) first.

This patient has sustained a major trauma, has had surgery and suffered a major personal loss with the death of her boyfriend. The first step in writing a care plan is to assess your patient. Assessment data has been given to you in the information provided. From the scenario, i have isolated the following abnormal data (problems):

• multiple fractures
• multiple lacerations
• multiple contusions on her face and body
• both legs have casts
• patient doesn't want to talk to anyone (assume this is an indication of her grief over the death of her boyfriend)
• wasn't able to take anything by mouth since her operation (this could be due to nausea from the anesthesia, an unknown injury in the accident you weren't told about, or grief over the loss of her boyfriend)
• temperature of 38.6 degrees (elevated)
• pulse 95
• b/p 130/90 (slightly elevated)
• pain [i've added this because it's reasonable to anticipate that the patient will have pain because of her injuries]

In step 2 of the care plan process you need to match these problems, or symptoms, with defining characteristics of nursing diagnoses that will apply to this patient. To do that you need your nanda nursing diagnosis reference book to confirm that you are matching these items to the correct nursing diagnoses. These are nursing diagnoses that will fit with these symptoms in the sequence of importance:

• imbalanced nutrition: less than body requirement r/t lack of interest in food aeb wasn't able to take anything by mouth since her operation
• impaired tissue integrity r/t traumatic injuries aeb multiple lacerations and multiple contusions on her face and body
• hyperthermia r/t trauma aeb temperature of 38.6 degrees
• impaired physical mobility r/t immobilization of legs aeb multiple fractures of bones with casts on both legs
• acute pain r/t traumatic injuries aeb elevated blood pressure and heart rate [patient would also be reporting she was having pain]
• grieving r/t death of boyfriend aeb patient doesn't want to talk to anyone
• risk for infection r/t traumatic tissue injuries
• risk for injury r/t immobility [thinking of the potential to develop a dvt here]

Now, that all the problems (defining characteristics) have been divided up and placed with nursing diagnoses, the next step is to develop goals and nursing interventions for them. So, you need to look in your nursing textbooks to find nursing care for:

• ways to encourage the patient to eat
• lacerations and contusions
• care of a patient with a fever
• an extremity with a cast, care of the cast
• interventions for the patient having pain
• how to help the patient deal with her grieving at the loss of her boyfriend and the emotional burden she has at this time
• actions you will need to take to avoid the patient developing an infection of any of her wounds
• actions you will need to take to help prevent the development of a dvt in her legs that have casts on them

Since this patient also underwent surgery a few other potential problems should be observed for and prevented:

• breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
• urinary retention
• constipation
• nausea/vomiting (due to paralytic ileus)

If you like, you can work them into the nursing diagnoses as other "risk for" diagnoses.

[Daytonite, BSN, RN]

Quote

Can someone help me to create nursing diagnoses for asthmatic patients?

The first step in choosing a nursing diagnosis involves assessing the patient. Any nursing diagnosis is always based upon the signs and symptoms the patient is having. These signs and symptoms are abnormal assessment items. Depending on how thorough your assessment of the patient is will determine how well your care plan is going to attend to the patient's problems.

With asthma, the patient is, in general, going to have these symptoms in order as an asthma attack worsens:

• hacking, non-productive cough (due to bronchial edema)
• restlessness
• diaphoresis
• only able to speak in short, broken phrases
• eventually the cough become productive of frothy, clear sputum
• breathlessness
• chest tightness
• dyspnea (shortness of breath)
• use of accessory respiratory muscles
• hyperresonance
• tachycardia
• some mild systolic hypertension
• inspiratory and expiratory wheezes
• crackles (as spasm and obstruction worsen)
• prolonged expiratory phase of respiration (due to bronchospasm)
• mucusal edema
• mucus plugging with mucus trapped behind airways that are narrowed or occluded
• diminished breath sounds
• cyanosis, lethargy, confusion and hypoxemia (as the patient proceeds to status asthmaticus or respiratory failure)

Based upon one or more of these above symptoms being present, nursing diagnoses that would be appropriate to use, in priority order, would be:

• gas exchange (abnormal skin color, confusion, cyanosis, diaphoresis, shortness of breath, hypoxemia, tachycardia, abnormal blood gases) - this diagnosis is generally used when there is hypoxia, hypoxemia or the patient is getting close to it
• ineffective breathing pattern (alterations in the depth of breathing, shortness of breath, orthopnea, prolonged expiratory phase of expiration, use of accessory respiratory muscles to breathe) - the act of breathing is not providing enough air
• ineffective airway clearance (any kind of cough, ineffective cough, any kind of adventitious breath sounds, any kind of changes in the rate or rhythm of the respirations, difficulty speaking due to breathing impaired, excessive sputum production) - this diagnosis is when the person is having difficulty clearing secretions from the respiratory passages in order to maintain a clear airway
• fear (fear of suffocation or death) - threats to the self that the patient recognizes as dangerous
• anxiety (obsessive tinkering with oxygen equipment, over attention to medication, treatment, physical symptoms) - warnings of impending danger causing patient to take measures to deal with threats

Examples of a nursing diagnostic statements using the above nursing diagnoses for an asthmatic patient might be:

• impaired gas exchange related to alveolar-capillary membrane changes as evidenced by cyanosis, lethargy, confusion and hypoxemia
• ineffective breathing pattern related to fatigue as evidenced by prolonged expiratory phase of respiration, shortness of breath and the use of accessory respiratory muscles to breathe.
• ineffective airway clearance related to airway spasm as evidenced by diminished breath sounds with inspiratory and expiratory wheezes and shortness of breath.
• fear related to threat of suffocation as evidenced by increased excitement and statements of "i'm not getting enough air!"
• anxiety related to fear of suffocation as evidence by patient constantly checking to make sure oxygen tubing is correctly positioned and asking what the setting of the oxygen flow is.

It would be very useful to have a book of nursing diagnoses or care plans that include the nanda definitions, defining characteristics and related factors since nanda is very specific about how each of the nursing diagnoses should be used.

[Daytonite, BSN, RN]

angie123 said:

Can anyone help me with 2 nursing diagnosis relating to pneumonia? I choose activity intolerance and infection.

Please read some of the posts in this thread. the only way you can "choose" any nursing diagnoses is if your patient with pneumonia has the symptoms that match with those nursing diagnoses.

The symptoms (defining characteristics) of activity intolerance are:

• abnormal blood pressure response to activity
• a abnormal heart rate response to activity
• electrocardiographic changes reflecting arrhythmias
• electrocardiographic changes reflecting ischemia
• exertional discomfort
• exertional dyspnea
• verbal report by the patient of fatigue
• verbal report by the patient of weakness

The definition of this diagnosis is "Insufficient physiological or psychological energy to endure required or desired daily activities". All of this above information comes directly from page 3 of nanda-I nursing diagnoses: definitions & classification 2007-2008 published by nanda international. Your patient should primarily be having shortness of breath upon physical activity and possibly arrhythmias and evidence of cardiac ischemia (chest pain, cyanosis, irregular heart rates). If this is not the case, then you shouldn't use this nursing diagnosis. If your patient has dyspnea on exertion, your nursing diagnostic statement would be written like this: activity intolerance (nursing diagnosis) related to exertional dyspnea (related factor) secondary to pneumonia as evidenced by shortness of breath upon ambulating 10 steps to the bathroom (patient symptom; abnormal assessment data item).

There is no official nanda nursing diagnosis of infection. Infection is a medical decision and medical diagnosis. You can, however, use nursing diagnoses for the manifested symptoms that the patient has of the infection, such as fever, leukocytosis (elevated white blood cell count), redness at a localized site of infection along with heat, pain, edema and sometimes loss of function due to the pain and swelling. (review the inflammatory response in a reference book on pathophysiology.) these symptoms you can develop nursing diagnoses for and, subsequently, nursing interventions.

[Eirene, ASN, RN]

I think those interventions are great! You are going to make one heck of a teaching guide for the new mommies!

I'm attaching some of my teaching care plans for when I went through ob. I hope you can get some ideas from them.

mother discharge instructions worksheet.doc

infant discharge instructions worksheet.doc

[Daytonite, BSN, RN]

scaregivr said:

I could use some help- for some reason I'm having trouble with outcome criteria. My patient's medical dx was hypercalcemia d/t hyperparathyroidism. My nursing dx is acute confusion rt electrolyte imbalance and dehydration aeb increased calcium level and hypovolemia.
These are my outcomes:

Pt will demonstrate restoration of cognitive status to baseline

Pt will obtain adequate amount of sleep

Pt will maintain optimal hydration and nutrition

I don't think this looks very good, and I can't even come up with a short term goal to go along with it. I really didn't do well on my last care plan due to this, so I'd like to at least make some progress. Can anyone give me some hints? Please?

In looking at the information you have posted, the primary reason that I see that you are having problems is that I cannot tell what you are basing your outcomes on. Outcomes, or goals, are the predicted results of our independent nursing actions (nursing interventions). Since you've listed none of your nursing interventions I can't tell whether these are good outcomes or not. Also, you cannot equate what you are doing as a nurse for a patient's problems with their medical diagnosis. That makes no sense. A doctor doesn't treat based on nursing problems and a nurse shouldn't treat based on medical problems either. We assess the patient for different things than the doctor does.

Please read the information on the post I listed above and I think that if you follow the information that is given there you will be able to write outcomes that you will be satisfied with. One thing that you must understand about care plans is that they are primarily based upon the assessment information that you gained. Everything you do in the planning stage of the care plan (formulating the outcomes and the nursing interventions) is based upon the symptoms, or abnormal assessment data, you obtained during assessment and has very little to do with the medical diagnosis except where some symptoms may be the same. Keep in mind that you are developing outcomes and nursing interventions for the patient's symptoms, so you need to be very clear about what the patient's symptoms are and you should have developed a list of them back when you were determining what nursing diagnoses to use.

And, by the way, your nursing diagnostic statement acute confusion rt electrolyte imbalance and dehydration aeb increased calcium level and hypovolemia is not put together correctly. You've diagnosed this incorrectly. The definition of acute confusion is abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time. (page 41, nanda-I nursing diagnoses: definitions & classification 2007-2008). Your aeb items should be the symptoms that support this definition. Do increased calcium and hypovolemia make you think immediately that the patient is confused? I don't think so! What you have described in your diagnostic statement is dehydration and belongs with this diagnosis: deficient fluid volume r/t active fluid volume loss aeb increased calcium level of ___ and confusion. Since you mention that this patient is dehydrated, I would also include other symptoms of the dehydration since there is bound to be more than just a low calcium level and confusion. Look at the defining characteristics (symptoms) that are listed with this diagnosis to see if you missed something in assessing this patient: deficient fluid volume (this is a link to a nursing diagnosis page from a nursing diagnosis book)

When you are determining nursing diagnoses, you need to use a nursing diagnosis reference of some sort either from a care plan book, a nursing diagnosis book, or the reference I listed above and check to make sure that the definition of the diagnosis, the related factors (etiology) and defining characteristics (symptoms) that are listed in the reference match with your patient. If they don't, then you can't diagnose the patient with it.

If you still want to use a nursing diagnosis of acute confusion for this patient you will have to restructure your nursing diagnostic statement. Nanda lists the related factors for this diagnosis as being the following (page 41, nanda-I nursing diagnoses: definitions & classification 2007-2008) and your patient must have one of these etiologies:

alcohol abuse delirium dementia drug abuse fluctuation in sleep-wake cycle over 60 years of age

Dehydration and electrolyte imbalance is not an etiology that they include for confusion. Therefore, your patient's confusion is more likely a symptom of his dehydration and belongs with fluid volume deficit unless he has one of these other etiologies for the confusion. Then, you need to have symptoms that prove the confusion. Nanda lists the symptoms as (page 41, nanda-I nursing diagnoses: definitions & classification 2007-2008):

fluctuation in cognition fluctuation in level of consciousness fluctuation in psychomotor activity hallucinations increased agitation increased restlessness lack of motivation to follow through with goal-directed behavior lack of motivation to follow through with purposeful behavior lack of motivation to initiate goal-directed behavior lack of motivation to initiate purposeful behavior misperceptions

Notice that you don't see the symptoms of increased calcium levels or hypovolemia listed there.

[elizabetta]

Hello everyone,

I am working on a caremap for a young women who just had a vaginal birth. I need to include diagnoses that include the families strengths? I was thinking of using effective breast feeding r/t infants weight gain

Would my goal/outcomes be : mother able to pick up on infants cues when hungry, decreased nipple soreness could be a sign of proper attachment to nipple. Mom states "it is going well" with a confident smile. I wouldn't have any interventions or evaluations right? I feel like I'm missing something. I'm not use to having patients that are doing this well. If someone could shed some light on this for me I'd appreciate it!

Also if you could think of any "positive: ND I'd appreciate it. Thank you!

Elizabeth

[Daytonite, BSN, RN]

elizabetta said:

Hello everyone,

I am working on a caremap for a young women who just had a vaginal birth. I need to include diagnoses that include the families strengths? I was thinking of using effective breast feeding r/t infants weight gain

Would my goal/outcomes be : mother able to pick up on infants cues when hungry, decreased nipple soreness could be a sign of proper attachment to nipple. Mom states "it is going well" with a confident smile. I wouldn't have any interventions or evaluations right? I feel like I'm missing something. I'm not use to having patients that are doing this well. If someone could shed some light on this for me I'd appreciate it!

Also if you could think of any "positive: ND I'd appreciate it. Thank you!

Elizabeth

You are barking up the wrong tree here. Effective Breast Feeding is a diagnosis has to do with the physiological need of nutrition and not with the family's strength.

Nursing diagnoses that might specifically apply to the family strength are:

• Readiness for Enhanced Family processes (NANDA definition: A pattern of family functioning that is sufficeint to support the well-being of family members and can be strengthened)
• Readiness of Enhanced Parenting (NANDA definition: pattern of providing an environment for children or other dependent person/s that is sufficient to nurture growth and development and can be strengthened.)
• Readiness for Enhanced Knowledge (specify) (NANDA definition: The presence of acquisition of cognitive information related to a specific topic is sufficient for meeting health-related goals and can be strengthened.)

In order to use any of them you need to look at a nursing diagnosis reference book that has these particular nursing diagnoses in it, look the definitions (I've already given them to you), defining characteristics and related factors of each to see if and how you can use them to fit in with your patient situation.

[Daytonite, BSN, RN]

homieboi said:

I have this patient in icu a male 41 years old. He is comatose gcs3. His diagnosis is acute respiratory failure with subdural hematoma secondary to fall. So I'm in charge of him and I got 35 degrees celcius actually his temperature doesn't go up in 35 above when I look at my thermometer. And he also got a bp of 80/60 mmhg. He is with endotracheal tube connected to mechanical ventilator and with the following settings of fi02 50% tv 450 bur 14 ac mode. I was asked to make 3 npcs. Im thinking to use hypothermia, ineffective breathing pattern, and hypotension but I can't use hypotension as my diagnosis. Can anybody help me to make my 3 diagnosis a proper one? I really appreciate anyone's help. Daytonite can you help me again? Thank you and god bless.

Nursing diagnoses have to be based upon the abnormal assessment data that you have collected on the patient. I suspect that there is more abnormal data than what you have posted. If you have diagnosed this patient with ineffective breathing pattern then he must have some of the symptoms of it, but you haven't listed any of them. Is he needing to be suctioned? There is a diagnosis that deals with an obstructed airway--ineffective airway clearance. This patient is comatose. How are his adls being met? There are many self-care deficits here. Is he being turned? A patient in a coma is always in jeopardy of getting pressure ulcers. There is a nursing diagnosis for that--risk for impaired skin integrity. How is the patient's nutrition being taken care of? Think about all the different things that are being done for this patient. They all can be classified as part of the problems that the patient has. You need to do a thorough assessment of this patient's nursing needs by adl (bathing, dressing, physical movement, eating, elimination, grooming) rather than focus on his medical diagnoses and the nursing problems (nursing diagnoses) will become more apparent. The adls that a patient needs assistance with or can't perform by themselves at all are patient problems that need to become part of the care plan. We are nurses and treat the patient's nursing problems, not his medical problems. In the icu the nurses can only do so much with the patient's respiratory and cardiac status and much of it is based on orders from the doctors.

[mkcrturner]

Yup, I got the careplan concept mastered.... Piece of cake....review patients problems- check,

Work backwards- check.

I was quite proud of myself.. Now comes the wrench.

I need to do nursing diagnosis and interventions on an imaginary pediatric patient with otitis and one with tonsillitis. I need 3 for each disease. I froze up and went blank, this is HARD. I have no m/b or AEB cuz there is no patient. 20 months of doing this based on what I am seeing, now I need to fake it??!! I LOVE nursing school! LOL

Anyway, I tried to be thoughtful, and I did not want to pull the 2 out of the book that I know most people in the class will use. We needed 3 FULL diagnoses with the r/t and m/b. Then we needed goals and interventions...

I muddled through tonsillitis, and for otitis I came up with:

1- Acute Pain R/T infectious disease process M/B patient complaints of pain in both ears (this is a gimme)

2- Anxiety, mild r/t hospitalization m/b decreased pulse and sleep disturbance.

3- Disturbed Sensory Perception: Auditory, r/t chronic otitis, m/b head tilting, pt cups ears with hands, pt cannot walk straight and states his “head is spinning”, pt states his ear hurts.

Be gentle, I know I do not have exact things like "pain is 8/10" but the instructor said to be real generic and include things that COULD be a symptom. This is what is throwing me for a loop. I cannot do a pretend person! LOL

Will these suffice? And if you have advice for interventions for the disturbed sensory perception I would love to hear them.

[Daytonite, BSN, RN]

Kelly, you are almost there. You actually have all the information you need-->a patient with a medical diagnosis so you can look up the signs and symptoms of that disease or medical condition in order to determine their nursing problems.

Your two patients have otitis (did they specify which type of otitis?) and tonsillitis. You need to look up the signs and symptoms of these two medical conditions and how the doctors diagnose and treat them. From that information you abstract how we nurses are going to deal with the situation. Many of the signs and symptoms of these conditions are the same signs and symptoms that we would also pick up when we do our assessment at the patient. You can also "imagine" what adl problems might be involved.

Some time ago I posted a whole bunch of websites to help students find information about...

I would suggest that after looking at the s/s and medical treatment of these conditions that you will find different nursing problems of a higher priority than anxiety, especially in a child. Children handle separation from their parents differently than adults, if they need to be hospitalized. They also have magical thinking about what happens during hospitalization or surgery, so their teaching needs are approached differently from adults.

By the way, the care plan concept is to assess the patient, analyze the abnormal data and determine what their nursing problems are and then to develop goals and interventions that are focused upon the abnormal data to:

• improve the patient's condition
• stabilize the patient's condition
• support the deterioration of the patient's condition

I hope that is what you were referring to by working backwards! be aware that sometimes the patient's nursing problem can't be fixed. Sometimes the best we can do is support the deterioration of the patient's condition, and that is ok.

[Daytonite, BSN, RN]

bailey88 said:

I need help with care plan for a schizophrenic (disorganized type )and nephropathy, has history of swallowing metal objects . Have done care plans on med-surg patients , but never on mental illness .
Any info would help . Thanks

All care planning begins with doing a thorough assessment of the patient. assessment includes:

• Collecting data from medical record
• Doing a physical assessment of the patient
• Assessing adl's
• Looking up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology--in this instance you need to look up information about
  • schizophrenia
  • nephropathy
  • ingestion of foreign objects

You want to isolate and make a list of the abnormal data that you discover during your assessment. That list of abnormal data is what you use to

• Choose nursing diagnoses
  • determine goals
  • develop nursing interventions