Are you scratching your head or are you maybe even ready to tear your hair out over how to come up with care plans? Here are some words of wisdom from our own beloved Daytonite.
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.
How does a doctor diagnose?
He/she does (hopefully) a thorough medical history and physical examination first. Surprise! We do that too! It's part of step #1 of the nursing process. Only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. Each medical diagnosis has a defined list of symptoms that the patient's illness must match. Another surprise! We do that too! We call it "critical thinking and it's part of step #2 of the nursing process. The NANDA taxonomy lists the symptoms that go with each nursing diagnosis.
Steps of the Nursing Process:
Assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)
Now, listen up, because what I am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. 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. Why? Because as a working RN, you will be using that method many times a day at work to resolve all kinds of issues and minor riddles that will present themselves. That is what you are going to be paid to do. Most of the time you will do this critical thinking process in your head. For a care plan you have to commit your thinking process to paper. And in case you and any others reading this are wondering why in the blazes you are being forced to learn how to do these care plans, here's one very good and real world reason: because there is a federal law that mandates that every hospital that accepts medicare and medicaid payments for patients must include a written nursing care plan in every inpatient's chart whether the patient is a medicare/medicaid patient or not. If they don't, huge fines are assessed against the facility.
You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids.
Simple Example
Steps One - Five
You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "what's wrong?" you're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it. A huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. What you have just done is step #1 of the nursing process--performed an assessment.
You determine that you have a flat tire. You have just done step #2 of the nursing process--made a diagnosis.
The little squirrel starts running like crazy in the wheel up in your brain. "What do I do?," you are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. Good thing you took that class in how to do simple maintenance and repairs on a car! You have just done step #3 of the nursing process--planning (developed a goal and intervention).
You get the jack and spare tire out of the trunk, roll up your sleeves and get to work. You have just done step #4 of the nursing process--implementation of the plan.
After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive. Good. Everything seems fine. The spare tire seems to be OK and off you go and on your way. You have just done step #5 of the nursing process--evaluation (determined if your goal was met).
Can you relate to that? That's about as simple as I can reduce the nursing process to. But, you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.
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.
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.
Care Plan Reality
What you are calling a nursing diagnosis (ex: activity intolerance) 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).
Definition: insufficient physiological or psychological energy to endure or complete required or desired daily activities
(does this sound like your patient's problem?)
Defining Characteristics (symptoms): abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness
Related Factors (etiology): bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle.
I've just listed above all the NANDA information on the diagnosis of activity intolerance from the taxonomy. Only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.
In order to choose nursing diagnoses, you also need to have some sort of nursing diagnosis reference. There is some free information on the internet but it is limited to about 75 of the most commonly used nursing diagnoses.
One more thing...
Care Plan Reality
Nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. They are all linked together with each other to form a nice related circle of cause and effect.
You really shouldn't focus too much time on the nursing diagnoses. Most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. The nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.
Hello Peeps, I need help with care plans for a stroke patient. I am currently doing a nursing care study of a stroke patient, a 73 yr old male, right sided MCA infarct, with left sided hemiparesis, dysathris of speech, expressive ashasia and hemianopia. You help and advice will be most appreciated. Thank you guys and gals.
You seem to be the most informative and knowledgeable in regards to Nursing Care Plans. I have enjoyed learning from you in-depth and comprehensive writings on the subject matter. Tonight (well now into the wee hours of the morning) I am having a hard time finding nursing diagnosis and interventions for positive attributes of a community.
The top three strengths I chose based on data from multiple sources are as follows: Communication and accessibility to news on community events. Multitude of emergency services provided with advanced training for community events. And final strength was the availability of health care insurance and the 90% rate of insured. I have four Care Plan books and not one of them gives me information on my particular problem. I would be grateful for any insight or direction in helping me complete this care plan.
Mandy
RN Student (FINAL SEMESTER!!!!! :yeah:if I don't go bonkers first )
I could use some help with my care plan! My Pt is a 50 yr old female with osteomyelitis, MRSA, diabetes mellitus, and PVD; she had her right leg amputated below the knee and most recently, had her 2nd toe amputated on her left foot. She now has a full thickness wound where it is healing on her foot, and she currently has a wound vac. I am thinking of focusing my care plan as follows: Impaired tissue integrity r/t altered circulation and impaired healing secondary to MRSA infection and osteomyelitus AEB full thickness wound healing by secondary intention on left foot @ site of 2nd toe amputation. Any help is GREATLY appreciated!!!!!
"in implementing a certain nursing intervention, what if the pateint would not cooperate with you? what will you do if ever he becomes aggresive and destructive?.."
mrs. t is a 22-year-old female who is 7 weeks pregnant (first trimester). she has been having an increasingly difficult time with nausea at all hours of the day. however, it is worse in the mornings. she has been unable to eat solid foods except in small bites and spread out throughout the day. thus far, she has not lost any weight, but she is worried about the health of herself and her baby. also, she has noticed that when the vomiting is at its worst, she does not urinate, the color is dark yellow and the odor is stronger than normal for her. she knows that she is supposed to be drinking extra fluids while she is pregnant, but she gets nauseated when she drinks more than a few sips.
nursing diagnosis:
deficient fluid volume r/t vomiting and nausea as evidenced by decreased urine output, increased urine concentration because unable to drink more than a few sips without getting nauseated and when vomiting is at its worst there is no urination, the color is dark yellow and the odor is stronger.
mrs. t is a 22-year-old female who is 7 weeks pregnant (first trimester). she has been having an increasingly difficult time with nausea at all hours of the day. however, it is worse in the mornings. she has been unable to eat solid foods except in small bites and spread out throughout the day. thus far, she has not lost any weight, but she is worried about the health of herself and her baby. also, she has noticed that when the vomiting is at its worst, she does not urinate, the color is dark yellow and the odor is stronger than normal for her. she knows that she is supposed to be drinking extra fluids while she is pregnant, but she gets nauseated when she drinks more than a few sips.
nursing diagnosis:
deficient fluid volume r/t vomiting and nausea as evidenced by decreased urine output, increased urine concentration because unable to drink more than a few sips without getting nauseated and when vomiting is at its worst there is no urination, the color is dark yellow and the odor is stronger.
you can also do risk for altered nutrition: less than body requirements since she hasn't been able to hold down her intake of solid foods therefore decreases absorption of nutrients. you can do the r/t =)
"In implementing a certain nursing intervention, what if the patient would not cooperate with you? What will you do if ever he becomes aggressive and destructive?.."
This is the time when you have to use therapeutic communication and help the pt open up to you ad tell you more about his/her feelings.
Nursing diagnosis help....please tell me if this is correct or not
A 22 year-old college student was admitted to the nursing unit following a diagnosis of severe periodontal infection. She states that the infection began 5 days ago with a small cold sore on the inside of her lip located on the right side of her jaw, and progressed rapidly to a full blown jaw infection. Upon examination, she is found to have severe swelling in the lower mandible especially on the right side. The gums are beefy red and there are several open wounds with purulent drainage from each. The skin superficial to the mandible is erythematous and hot to the touch. Since yesterday, she has begun choking on the drainage from the wounds because she is unable to close her mouth in order to swallow correctly. Also, she states that she is losing some sensation in her mouth and throat from the swelling and can no longer tell when there is fluid in her throat and when there is not. She worries that she will choke in the middle of the night.
My Diagnosis:
Impaired oral mucous membrane related to inflammation secondary to infection as evidenced by a small cold sore that started inside the lip, severe swelling on the lower mandible, gums that are beefy red with several open wounds which are draining purulence, superficial skin is erythematous and hot to the touch, choking on the drainage because unable to close mouth and swallow correctly and loss of sensation in the mouth and throat.
)
Derro-Dublin-Ireland
4 Posts
Hello Peeps, I need help with care plans for a stroke patient. I am currently doing a nursing care study of a stroke patient, a 73 yr old male, right sided MCA infarct, with left sided hemiparesis, dysathris of speech, expressive ashasia and hemianopia. You help and advice will be most appreciated. Thank you guys and gals.