Feeling like I'm diagnosing

FireStarterRN, BSN, RN · Mar 16, 2009

Nobody really uses careplans after nursing school, they are more of an educational tool. I wouldn't worry about it. Just do what you need to do to satisfy your instructors.

Daytonite, BSN, RN · Mar 17, 2009

a care plan is a determination of the nursing problems that a patient is having. the term, diagnosis, merely means a decision or opinion that one makes after the process of examination or investigation of the facts. medicine and nursing are not the only professions that "diagnose". police detectives, car mechanics and plumbers also diagnose. in fact, diagnosis is merely part of problem solving and many professions are engaged in problem solving. nursing now has a well ordered set of diagnoses (the nanda nursing diagnoses) to assist us. we use the nursing process as a tool in helping us to do this problem solving. as nurses we are interested in patient's responses to their medical diseases or conditions. think about it. their difficulty performing adls, problems breathing, moving--all are their responses to their medical diseases or conditions. our job is to assist them in dealing with them.

how do u make a plan for a patient that don't have abc's problem the only problem is the femoral fracture that was taken care by orif procedure. they are not having no complication is this when we use potential problems.

we first assess all of the following:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications they are taking

the complications of general anesthesia should also be considered:

breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
hypotension (shock, hemorrhage)
thrombophlebitis in the lower extremity
elevated or depressed temperature
any number of problems with the incision/wound (dehiscence, evisceration, infection)
fluid and electrolyte imbalances
urinary retention
constipation
surgical pain
nausea/vomiting (paralytic ileus)

if they have no actual problems, then potential problems are considered. if the patient needed no nursing care or monitoring of some type, they wouldn't be taking up a hospital bed. remember that we also carry out physician's orders.

a patient who has had an orif for a fracture had a trauma. did they fall? why? was any syncope involved? if it was then the reason for the syncope needs to be considered because the patient could fall again. the patient now has mobility problems, skin problems, pain, needs to be deep breathing and coughing because of having undergone anesthesia and may have self-care deficits because of the mobility problem. try to anticipate the problems the person will have at home when they are discharged. a walker or can may be needed. whatever led to the fall needs to be addressed so it doesn't happen again. you should read about orif in your textbook or on the internet.

http://jama.ama-assn.org/cgi/reprint/298/20/2442.pdf
- hip fracture and methods of stabilization
http://www.orthogate.org/patient-education/hip/hip-pinning-surgery-for-a-fractured-hip.html
- hip pinning (orif)

there is information on how to write a care plan on this sticky thread:

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

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help with care plans

Daytonite, BSN, RN · Mar 17, 2009

Nobody really uses careplans after nursing school, they are more of an educational tool. I wouldn't worry about it. Just do what you need to do to satisfy your instructors.

What an awful unhelpful thing to advise a student!

That is incorrect. Care plans are required documentation by federal law (Title 42) in charts in acute hospitals and LTC facilities that receive any type of federal funds which is pretty much 99.9% of them. It documents the nursing process in problem solving each patient's nursing problems. I wrote many of my patient's care plans. It was part of my job to do that. As long as the federal law remains in place care planning will be taught to students and it will remain a job requirement.

FireStarterRN, BSN, RN · Mar 17, 2009

Oh yes. we fill out the careplan sheets on admit, but nobody ever looks at them after that. That is a very good example of how federal bureaucratic oversight makes more useless busy work for nurses. I'm just telling the OP the truth. Bedside, acute care nurses universally think careplans are stupid and useless.

The object of filling out the careplan is entirely to avoid being dinged on surveys. They are utterly useless otherwise.

Daytonite, BSN, RN · Mar 18, 2009

Oh yes. we fill out the careplan sheets on admit, but nobody ever looks at them after that. That is a very good example of how federal bureaucratic oversight makes more useless busy work for nurses. I'm just telling the OP the truth. Bedside, acute care nurses universally think careplans are stupid and useless.
The object of filling out the careplan is entirely to avoid being dinged on surveys. They are utterly useless otherwise.

How do you know who else looks at the chart? I've not only been a manager but worked in coding and HIM as well. Nurses and doctors are may generate the documentation, but many others look at it! Don't be so parochial and think that nurses are the only ones looking at those charts! Many eyes fall upon what we put into those charts including the care plans.