Desperately Need Help With Care Plans

Any help with care plans will be appreciated?

Specializes in med/surg, telemetry, IV therapy, mgmt.

I've expanded on two of your nursing diagnoses for you and added goals and outcomes. Outcomes are the predicted results of our independent nursing actions. Independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. Goals are the predicted results of collaborative nursing actions. Collaborative nursing actions are those things nurses can only do for patients with an order of a physician or another healthcare provider--things like administer medications or provide certain treatments, etc. Both outcome and goal statements should be measurable, patient centered and specific. Below the outcomes and goals I've listed weblinks to specific nursing diagnosis pages on two different care plan constructor sites where you can get not only information about the definition of that particular nursing diagnosis, it's related factors, defining characteristics and outcomes, but nursing interventions with rationales as well.

Chronic pain r/t progressive enlargement of tumor secondary to cancer of the pancreas with metastasis to the liver aeb patient's subjective rating of pain on a numeric scale of 1 to 10

Outcome: by ____ the patient will be able to perform normal adls with minimal interference from pain and the side effects of his medication.

Goal: by ____ the patient will state his pain is improved.

Imbalanced nutrition: less than body requirements r/t increased metabolic demands of tumor secondary to cancer of the pancreas with metastasis to the liver aeb 91% of body weight loss and poor appetite

Outcome: by ____ the patient will state the importance of a well-balanced diet

Goal: by ____ the patient will ingest nutritional requirements in accordance with his level of activity and metabolic needs.

Goal: by ____ the patient will maintain his current weight of ____.

Ineffective coping r/t

(You need to look at both of the sites below. Decide what it is that is making coping with his cancer difficult for this patient and you will then be able to complete your "related to" part of this diagnostic statement. Why do you feel this patient is not coping with his disease well?)

A soap note, generally, looks like this:

S - "This is my very first care plan and I do not feel as if I was given enough instruction on how to do this." "How do I come up with interventions and evaluations and goals."

O - Completed data collection, no grouping of abnormal data into nursing diagnoses, no goals or outcomes, no nursing interventions. care plan halted at step #2.

A - Readiness for enhanced knowledge of nursing process r/t an expressed interest in learning how to write a care plan aeb a written plea for help

P - Assist student with formulation of nursing diagnostic statements, provide information on difference between outcomes and goals, provide references for nursing interventions, provide information on soap charting.

Hello,

What is the difference between NANDA nursing diagnosis and wellness diagnosis?

Thank you for your attention.

Have an excellent night!

Specializes in med/surg, telemetry, IV therapy, mgmt.
yadis572002 said:
What is the difference between nanda nursing diagnosis and wellness diagnosis?

A nursing diagnosis is a patient problem that has been identified through the collection of information obtained in assessing the patient. There are currently 188 official nanda nursing diagnoses [as of 2007] that have specified definitions and criteria. Among these nanda nursing diagnoses are several wellness diagnoses.

Nanda defines the wellness nursing diagnosis as "describ[ing] human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. This readiness is supported by defining characteristics. As with all diagnoses, nurse-sensitive (sensitive to nursing interventions) outcomes are identified and nursing interventions are selected that will provide a high likelihood of reaching the outcomes." (page 332, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international.)

Here are the wellness nursing diagnoses in the Nanda II Taxonomy:

  • readiness for enhanced comfort
  • readiness for enhanced organized infant behavior
  • readiness for enhanced nutrition
  • readiness for enhanced self-care
  • readiness for enhanced sleep
  • readiness for enhanced spiritual well-being
  • readiness for enhanced religiosity
  • readiness for enhanced urinary elimination
  • readiness for enhanced fluid balance
  • readiness for enhanced therapeutic regimen management
  • readiness for enhanced communication
  • readiness for enhanced community coping
  • readiness for enhanced family coping
  • readiness for enhanced coping
  • readiness for enhanced decision making
  • readiness for enhanced hope
  • readiness for enhanced knowledge (specify)
  • readiness for enhanced family processes
  • readiness for enhanced parenting
  • readiness for enhanced self-concept
  • readiness for enhanced power
  • readiness for enhanced immunization

(Reference: pages 282 - 294, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international.)

I want to thank everyone at this site, it has made understanding careplans manageable. I have shared the information with the other students in my class.

I have a new pt and some more questions. Pt has mets breast cancer, stage 4 and it has spread to her bones. She needs help with ALDs but can stand (for a moment) on her own and can move around in bed and PT is working on her walking short distances.

She has HTN, DM II, depression, bipolar, anemia, asthma, constipation, sleep apnea, migraine, incontinence. These are all being treated with numerous meds. She has had breast cancer for past 10 yrs and both breasts removed and reconstruced, she did XRT in the past and has just started on oral chemotherapy that is given a difficult but slight chance of being effective. she is in a long term care unit with a full code. She wants to be able to walk again so she can go home to her mother that is in a wheelchair.

She is on oxycodone q4h and is in bed or in her chair a lot- a 19 on the Braden scale.

What I have come up with for my three nx are chronic pain, inadequate nutrition:less than body requirements, and risk for injury r/t DM- hypo or hyperglycemic. My question is: Are these good or should I have other priorities & how do you put DM related NX when the DM is under control and she is not on insulin. She has HTN put no complication currently, She has asthma and gets RT treatments.

Am I on the right track. the problem I have currently is I am not sure how to prioritize- I keep looking at Maslows and reading more about it but when someone is on palliative care I am not sure how that impacts Maslows.

Thank you in advance

tygge

Specializes in med/surg, telemetry, IV therapy, mgmt.

Some thoughts for tygge on your care plan. . .You ALWAYS, ALWAYS, ALWAYS let your patient's abnormal assessment data guide you in the choosing and prioritizing of nursing diagnoses. As I was reading your post I was making a list of them. What is your supporting assessment data for using Imbalanced Nutrition: less than body requirements? Has she been losing weight? Or, is she having nausea secondary to the chemo? Is there a reason you didn't address her incontinence? Breast cancer often metastasizes to the lung as well as the bone. With a history of asthma I would be thinking this patient is at risk and needs watching for breathing or airway problems. Getting this lady back into her home is going to be a discharge and social service project because it sounds like her mother is not going to be able to be much help to her. Since she has stated that getting back home is one of her desires, it would seem to me that this needs to be included in the care plan.

Maslow has defined the levels of his hierarchy. Most understand that in his theory physiological needs must be addressed first. However, the physiological needs are further prioritized and sequenced in the following order of importance:

  1. oxygen requirements (brain first, then the heart, lungs, kidneys and peripheral tissues)
  2. food and fluids (this includes electrolytes)
  3. elimination (urine and feces)
  4. thermoregulation (fevers)
  5. sex
  6. movement
  7. rest
  8. comfort (pain control, some of the self-care deficits)

The next tier of priority is safety needs. They are prioritized in the following order of importance:

  1. safety from physiological/psychological threats
  2. protection
  3. continuity
  4. stability
  5. lack of danger

Your proposed nursing diagnoses as listed, plus the one you decided to add that you mentioned to me in a private message would be prioritized according to Maslow and following NANDA guidelines this way:

  1. Imbalanced Nutrition: less than body requirements
  2. Impaired Mobility
  3. Chronic Pain
  4. Risk for Injury

Anticipated problems are always sequenced last. If there are more than one, they are prioritized and sequenced according to where they would fit on the Maslow hierarchy as if they were real problems, but within their own little grouping of "Risk for" diagnoses at the end of the diagnostic list.

I didn't list as much supporting data as I could have since it was quite lengthy. re: nutrition, she was 200# and is now down to 171#. and they give her meal supplements regularly. From the chart it seems as if her cancer has spread to her spine and leg bones. I didn't see anything about it spreading to lungs except that they did a breathing treatment on her. She appears to have no trouble breathing when I have seen her and her lungs sound were good. We are only there a short time so it is hard to get a big picture, so I relied heavily on her chart. The reason I didn't address the incontinence is that she is able to use the bathroom with assistance and her incontinence is not specified. When I assisted her to the bathroom I didn't see any sign of skin irritation though she does wear an adult brief. she moves around in bed often so she is not high for bed sores but she does have a high risk for falls. She is assisted any time she gets out of bed. Mainly transfer to chair though PT is helping her try to walk a few days a week.

I put pain first since that seemed to be the priority since she is in a long term care facility and on palliative care but I will reassess my priorities with the insight you provided.

It would help if we were able to talk to the nurses about the pt and get their insight, but we mainly interact with the CNAs since this is our first quarter.

thank you for your insights and I will rework my care plan

tygge

I'm sure that "risk for" diagnoses do not require an AEB. It makes sense because a patient can't be presenting evidence of something that hasn't happened yet, correct?

If someone has a source for this I would really really appreciate it!:balloons:

Specializes in med/surg, telemetry, IV therapy, mgmt.
hotdog19d said:
Ok, I understand that aeb is not required,but can anyone help find a source that states this in black and white? I looked through my nursing diagnosis book and although it doesn't provide defining characteristics for "risk for's". I can't find anywhere in the book that states why.

Per nanda, the term "risk" belongs in one of the seven axial systems of taxonomy ii (for nursing diagnoses). It is classified under axis 5 health status and officially defined as "vulnerability, especially as a result of exposure to factors that increase the chance of injury or loss." (page 237, Nursing Diagnoses: Definitions & Classification 2005-2006 published by nanda international). With regard to using any of the terms within the seven axes to construct nursing diagnostic statements, nanda states the following: "some words of caution as well as encouragement: Using a multiaxial structure allows many diagnoses to be constructed that have no defining characteristics and may be nonsense (such as "impaired activities of daily living, fetus"). We urge you to use only those diagnoses that are approved for testing and thus have defining characteristics. (page 239, nursing diagnoses: definitions & classification 2005-2006 published by nanda international). Color and boldface added by me.

What that all means, hotdog19d, is that there will be no nanda approved "risk for" nursing diagnoses that are going to have any defining characteristics as said in the post by bookwormom.

Most people find the materials from nanda kind of boring to read. However, if knowing about these things from the source is important to you, you can get a copy of Nursing Diagnoses: Definitions & Classification from nanda very easily.

Go to their website http://www.nanda.org/ and order a copy.

This is how I got my copy of the 2005-2006 edition I referenced above. A new edition is coming out for 2007-2008 and the cost is $24.95.

Besides listing all the approved diagnosis (this information is reprinted in scores of nursing care plan books), it also gives an explanation of what the taxonomy and classification system is as well as lists of all the words that are included in each of the seven axes that comprise the taxonomy (not often included in nursing care plan books). Warning! This is taxonomy stuff is something that only geeks are likely to be interested in.

This is my 1st case study. My client has urinary incontinence. A 75 yr old lives alone in a continuing care retirement home, w/no family. She has had difficulty with urinary leaking when sneezing,coughing. She gets up @ night 4-5 times a night afraid of wetting bed. Each time at night she has fallen when getting up. She drinks 4 glasses of fluid a day, and never after 5 pm. Also I need a nursing diagnosis with goals, and three interventions. I need to address:

1. What assessment questions do i need to ask regarding incontinence risk factors.

2. Formulate nursing diagnosis and goals.

3. What type of incontinence dos she have

4. Write a nursing diagnosis,a goal,& interventions

5. What questions do u ask to determine fall risks

Here is my nursing diagnoses - Am I right?

1. Incontinence urge

2. Risk for injury r/t falls

3. Sleep disturbance

4. Fear risk for loneliness r/t living by self in retirement home.

My assessment: assess gait, balance, eyes, medications, tests for UTI, parkinsons.

Should I consider alcohol use? why/why not?

Also I need to make a diagram illustrating age related changes in urinary system. Any help will greatly be appreciated. Thank you so much!

Don't forget impaired skin integrity r/t incontinence.

How about something like poor body image r/t incontinence? Maybe something on the psychological issue of continued incont? Been a while since I did a care plan, but I kinda' remember some diagnoses like that.

Specializes in med/surg, telemetry, IV therapy, mgmt.

I have read both the threads you have posted on this case scenario. Based on what you've posted to both threads this is my reply.

With regard to the incontinence. . .

It sounds like the scenario is describing stress incontinence which is the inability to prevent urination during the stress of such activities as coughing, sneezing, lifting or laughing. It is normally due to muscle weakness and is common in women who have had a history of lady partsl deliveries of children. Assessment questions you want to ask with regard to incontinence are things such as:

  • When does it occur?
  • Is the incontinence related to any activity such as coughing, sneezing, lifting or laughing? (yes)
  • Does the incontinence occur at any other times?
  • How long has this been happening?
  • Did it start suddenly? or did develop gradually over time?
  • What was the normal pattern of urination during the day? during the night?
  • Has the urine changed color?
  • Has the urine developed a change in odor?
  • Is there any urgency?
  • Is there any starting and stopping of the urinary stream?
  • What kind of fluid and how much is being drunk during the day? is the fluid restriction being followed?
  • Is the patient on any medication that could be affecting urination?

With regard to the problem of falling. . .

The elderly frequently fall due to gait and balance problems. This is a link to 3 gait and balance assessment tools that are used for elderly patients that will give you an idea of what is assessed in patients who might be at risk for falling and the questions you should ask.

Assessment questions you want to ask with regard to falling might be such things such as:

  • Are there any physical deformities of the lower extremities?
  • How much range of motion does the patient have in each of the joints of the lower extremity?
  • How much muscle strength is present in the muscles of the lower leg?
  • Does the patient have any weakness in one or both legs?
  • Is the patient unable to move one or both legs?
  • Does the patient stumble or trip when walking?
  • Does the patient have difficulty getting out of the bed?
  • Is the patient having any muscle spasms or cramps in one or both legs upon standing? if so, what makes it worse? what makes it better? is the patient on any diuretics?
  • Does the patient have any pain or stiffness in the joints of the hip, knee or ankle? describe the pain. is it radiating, burning, sharp, dull or aching in nature?
  • Does anything make the pain worse? does anything make the pain better?
  • Is there any swelling or pain anywhere in the lower extremities that might be interfering with movement?
  • Is there any stiffness in the joints upon attempting to arise from the bed or a sitting position?
  • Is the patient overweight?
  • Can you palpate pulses?
  • Is the skin warm to touch? or, cool?
  • What did the last set of electrolytes look like?
  • When did this falling during the night begin?
  • Has it happened before? or, is it a new problem?

I am curious as to why you ask if you should consider if the patient is using etoh (alcohol). Unless this question was asked as part of the scenario, i wouldn't even consider that the patient might be abusing alcohol. How would etoh figure in with a patient who was on a fluid restriction, getting up to the bathroom 4 to 5 times a night and falling when getting up? Although alcoholics are prone to falls, they are also prone to a number of other problems as a result of long term usage:

  • peripheral neuropathy
  • brain damage
  • seizures
  • hallucinations
  • severe memory problems
  • confusion
  • a number of personality disorders
  • major depression
  • anxiety
  • cirrhosis
  • vitamin deficiencies

This article from the american family physician includes a list of the symptoms of alcoholism in the elderly. You can use it as a guideline to develop a list of questions to develop for an assessment of alcoholism in your case scenario patient:

Alcoholism in the Elderly

From my knowledge of working with alcoholics in detox i would say you don't have enough evidence to suggest that this patient has an alcoholic problem unless there are other symptoms that you have not listed in your posts.

Based on the information you supplied, i believe there are only two good nursing diagnoses that you can come up with. I only have one online link to a nursing diagnosis where you can get outcomes and nursing interventions. Also, for the stress incontinence you really don't have enough information to determine the etiology (related factor) of the incontinence although we know it is most likely due to muscle weakness. One of the interventions for stress incontinence is to instruct the patient in kegel exercises.

  1. Types of Urinary Incontinence
  2. Slideshow: Urinary Incontinence in Women
  3. What Causes Urinary Incontinence in Men?

I would not use disturbed sleep pattern as one of my nursing diagnoses because the cause of the interrupted sleep pattern is related to urinating. The reason for the frequent urination is not clear to me as to whether the patient is self-waking to go to the bathroom or there is some other factor, either physical or pathological that needs to be determined. There may not be a sleep problem at all.

Likewise, I wouldn't use risk for loneliness either. Use of this nursing diagnosis presupposes that the patient would experience depression, restlessness, anxiety or unhappiness as a result of some type of isolation or deprivation. However, this patient is living in a retirement community and there is no other evidence of isolation or deprivation to support using this diagnosis.

Your goals or outcomes should reflect what you are trying to accomplish with the nursing interventions you are prescribing and they are the predicted results of your interventions. Remember to make them measurable, patient centered and specific and state a specific deadline by which they should be achieved.

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