First care plan help - stuck at step 1 writing the nursing diagnosis

Double-Helix, BSN, RN · Apr 4, 2012

Since each area of knowledge deficit is a separate problem and requires separate interventions, they should each be listed as a separate diagnosis. However, I would not choose two knowledge deficit diagnoses for your care plan. Using one is fine, but then choose another of higher priority, such as one related to airway, breathing or circulation.

The correct way to write the diagnosis is the second way that you listed. Smoking cessation is the knowledge deficit, it's not the related to factor. The related to section includes the reasons that the patient has a knowledge deficit. So the correct way to write it is Knowledge Deficit: smoking cessation related to _________.

The related to factors are specific to your patient. For what reasons does your patient have a knowledge deficit? Those are the reasons that you list in your related to section. The ones in the book may not all apply to your patient, or they may be additional applicable factors that are not listed in the book.

Esme12, ASN, BSN, RN · Apr 4, 2012

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

there are many nurses here and many who came before me to this site but one nurse stands out.....i use her post all of the time as you can't improve on perfection.........daytonite(rip) https://allnurses.com/general-nursing...ns-286986.html

you can also use the search on this site to lead you to care plans.

daytonite.

care plan basics:

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

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:

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)

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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.

care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

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.

is this based on a real patient? what was your assessment? what was the patient complaint? if you combine what is related to your nursing diagnosis you should be able to measure the outcome equally and utilize the same interventions. you could say ineffective health maintenance r/t safe sexual behavior as evidenced by unsafe/high risk sexual behaviors. then deficient knowedge:smoking cessation r/t health maintenance as evidenced by smoking x amount per day.

ineffective health maintenance

nanda-i definition: inability to identify, manage, and/or seek help to maintain health

common related factorsperceptual/cognitive impairment

presence of physical disabilities or challenges

presence of adverse personal habits:

smoking
poor diet selection
morbid obesity
alcohol abuse
drug abuse
poor hygiene
lack of exercise

low income/lack of material resources

lack of access to care

lack of knowledge

poor housing conditions

ineffective coping

risk-taking behaviors

inability to communicate needs adequately (e.g., deafness, speech impediment)

dramatic change in health status

lack of support systems

denial of need to change current habits

defining characteristicsbehavioral characteristics:

demonstrated lack of knowledge
failure to keep appointments
expressed interest in improving behaviors
failure to recognize or respond to important symptoms reflective of changing health state
inability to follow instructions or programs for health maintenance

physical characteristics:

body or mouth odor
unusual skin color, pallor
poor hygiene
soiled clothing
frequent infections (e.g., upper respiratory infection, urinary tract infection)
frequent toothaches
obesity or anorexia
anemia
chronic fatigue
apathetic attitude
substance abuse

deficient knowledge

nanda-i definition: absence or deficiency of cognitive information related to specific topic

common related factors

new condition, procedure, treatment

complexity of treatment

cognitive/physical limitation

misinterpretation of information

decreased motivation to learn

emotional state affecting learning (anxiety, denial, or depression)

unfamiliarity with information resources

lack of recall

defining characteristics

verbalizing inaccurate information

inaccurate follow-through of instruction

questioning members of health care team

incorrect task performance

expressing frustration or confusion when performing task

deficient knowledge (specify)the (specify) means you need to name the subject of your teaching area. it is quite appropriate to have multiple subjects, just as it is appropriate to have multiple related factors or symptoms. include all that apply.gulanick: nursing care plans, 7th edition

these resources may help.

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

nurseprnRN, BSN, RN · Apr 4, 2012

students often get seduced by a sexy-sounding nursing diagnosis, and then have the devil's own time trying to cram assessment data into it. this is exactly backwards. you do your data collection and analysis first, then you make your diagnosis. you wouldn't think much of physician who put your leg in a cast for fracture without ever having examined you, taken a history, or done an xray. same thing. i can see as your faculty have already started to confuse you on this point by giving you nursing diagnoses for this patient. i hope the data they gave you support them (i have to think they do).

in answer to your question, yes, the nanda-i nursing diagnoses are da bomb, and their defining characteristics are, well, defining. they are it. this is why you look at those first and then make the diagnosis. sorta like a physician would say, "patient fell in a hole and experienced a sharp pain and heard a crackig sound. leg is deformed between ankle and knee, diagnostic imaging shows medial tibial fracture. impression (this is what you would call a diagnosis): tibial fracture. plan: cast, return to clinic 1 week for followup." for a nursing diagnosis you look at the diagnoses you might be considering, then see how the things you measured/saw/learned from the chart match up with defining characteristics for the diagnoses. some will work, some won't.

tsm007 · Apr 4, 2012

Since each area of knowledge deficit is a separate problem and requires separate interventions, they should each be listed as a separate diagnosis. However, I would not choose two knowledge deficit diagnoses for your care plan. Using one is fine, but then choose another of higher priority, such as one related to airway, breathing or circulation.
The correct way to write the diagnosis is the second way that you listed. Smoking cessation is the knowledge deficit, it's not the related to factor. The related to section includes the reasons that the patient has a knowledge deficit. So the correct way to write it is Knowledge Deficit: smoking cessation related to _________.
The related to factors are specific to your patient. For what reasons does your patient have a knowledge deficit? Those are the reasons that you list in your related to section. The ones in the book may not all apply to your patient, or they may be additional applicable factors that are not listed in the book.

Thank you for your response. I actually figured out on my own that I would have to separate them into two separate diagnosis because it would just be impossible to write out interventions in a plan jumping from one focus to the next. I also had already planned to use a higher priority for the second diagnosis, but thought it would be useful to figure out how to write a deficient knowledge diagnosis. Plus there were only 4 diagnosis to choose from.

tsm007 · Apr 4, 2012

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.
there are many nurses here and many who came before me to this site but one nurse stands out.....i use her post all of the time as you can't improve on perfection.........daytonite(rip) https://allnurses.com/general-nursing...ns-286986.html
you can also use the search on this site to lead you to care plans.
daytonite.

care plan basics:
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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.
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:
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)
a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.
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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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.
care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

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.
is this based on a real patient? what was your assessment? what was the patient complaint? if you combine what is related to your nursing diagnosis you should be able to measure the outcome equally and utilize the same interventions. you could say ineffective health maintenance r/t safe sexual behavior as evidenced by unsafe/high risk sexual behaviors. then deficient knowedge:smoking cessation r/t health maintenance as evidenced by smoking x amount per day.
ineffective health maintenance
nanda-i definition: inability to identify, manage, and/or seek help to maintain health
common related factorsperceptual/cognitive impairment
presence of physical disabilities or challenges
presence of adverse personal habits:
smoking
poor diet selection
morbid obesity
alcohol abuse
drug abuse
poor hygiene
lack of exercise
low income/lack of material resources
lack of access to care
lack of knowledge
poor housing conditions
ineffective coping
risk-taking behaviors
inability to communicate needs adequately (e.g., deafness, speech impediment)
dramatic change in health status
lack of support systems
denial of need to change current habits
defining characteristicsbehavioral characteristics:
demonstrated lack of knowledge
failure to keep appointments
expressed interest in improving behaviors
failure to recognize or respond to important symptoms reflective of changing health state
inability to follow instructions or programs for health maintenance
physical characteristics:
body or mouth odor
unusual skin color, pallor
poor hygiene
soiled clothing
frequent infections (e.g., upper respiratory infection, urinary tract infection)
frequent toothaches
obesity or anorexia
anemia
chronic fatigue
apathetic attitude
substance abuse
deficient knowledge
nanda-i definition: absence or deficiency of cognitive information related to specific topic
common related factors
new condition, procedure, treatment
complexity of treatment
cognitive/physical limitation
misinterpretation of information
decreased motivation to learn
emotional state affecting learning (anxiety, denial, or depression)
unfamiliarity with information resources
lack of recall[h=4]defining characteristics[/h]verbalizing inaccurate information
inaccurate follow-through of instruction
questioning members of health care team
incorrect task performance
expressing frustration or confusion when performing task
deficient knowledge (specify)
the (specify) means you need to name the subject of your teaching area. it is quite appropriate to have multiple subjects, just as it is appropriate to have multiple related factors or symptoms. include all that apply.
these resources may help.
nursing care plan | nursing crib
nursing care plan
nursing resources - care plans
nursing care plans, care maps and nursing diagnosis
http://www.delmarlearning.com/compan.../apps/appa.pdf

yes, i actually discovered her posts already. even went as far to look to see if she was still around. her posts are amazingly helpful. thanks for the links.

tsm007 · Apr 4, 2012

students often get seduced by a sexy-sounding nursing diagnosis, and then have the devil's own time trying to cram assessment data into it. this is exactly backwards. you do your data collection and analysis first, then you make your diagnosis. you wouldn't think much of physician who put your leg in a cast for fracture without ever having examined you, taken a history, or done an xray. same thing. i can see as your faculty have already started to confuse you on this point by giving you nursing diagnoses for this patient. i hope the data they gave you support them (i have to think they do).

in answer to your question, yes, the nanda-i nursing diagnoses are da bomb, and their defining characteristics are, well, defining. they are it. this is why you look at those first and then make the diagnosis. sorta like a physician would say, "patient fell in a hole and experienced a sharp pain and heard a crackig sound. leg is deformed between ankle and knee, diagnostic imaging shows medial tibial fracture. impression (this is what you would call a diagnosis): tibial fracture. plan: cast, return to clinic 1 week for followup." for a nursing diagnosis you look at the diagnoses you might be considering, then see how the things you measured/saw/learned from the chart match up with defining characteristics for the diagnoses. some will work, some won't.

i'm kind of figuring out how this works as i work through writing it. i am supposed to work through the assessment data and find the data that supports this as well. that is proving to be more challenging using a prewritten assessment. it'd be much easier if i could do the assessment myself so i could ask the questions that i want to use for my data, but i can work with what is provided.

morte, LPN, LVN · Apr 4, 2012

I'm kind of figuring out how this works as I work through writing it. I am supposed to work through the assessment data and find the data that supports this as well. That is proving to be more challenging using a prewritten assessment. It'd be much easier if I could do the assessment myself so I could ask the questions that I want to use for my data, but I can work with what is provided.

if you are not finding sufficient data, perhaps the ND needs changing?

tsm007 · Apr 4, 2012

if you are not finding sufficient data, perhaps the ND needs changing?

I'm only having problems with the objective data. I have lots of subjective data for a deficient knowledge ND, but hardly anything to use for objective.

morte, LPN, LVN · Apr 4, 2012

what objective data have you been given?

I'm only having problems with the objective data. I have lots of subjective data for a deficient knowledge ND, but hardly anything to use for objective.

tsm007 · Apr 4, 2012

what objective data have you been given?

No vitals, not that they would be relevant to this ND anyway. I have age, number of sexual partners (but I think that's subjective), past history of hepatitis B, the rest is mostly stuff on her diet, religion, and social history. There is other data that relates to the primary ND, but we are supposed to be writing secondary ND which I probably should have mentioned in my first post.

morte, LPN, LVN · Apr 4, 2012

No vitals, not that they would be relevant to this ND anyway. I have age, number of sexual partners (but I think that's subjective), past history of hepatitis B, the rest is mostly stuff on her diet, religion, and social history. There is other data that relates to the primary ND, but we are supposed to be writing secondary ND which I probably should have mentioned in my first post.

OK, where is the smoking hx?