I am doing my first care plan and I have a question

  1. We are doing our first care plans this week and I want to make sure I am going in the right direction. Any advice would be GREATLY appreciated, as I feel like we've been thrown in the water with no life preserver and I am not sure what to do!

    Okay, my patient (61 F) has Diabetes, and has had it since she was pregnant with her first child. She has a lot of complications that have gradually developed over the years, but by talking with her, I don't get the impression that it is due to her negligence of care, rather I think it's just the progression of the disease. She eats the correct diet, takes her insulin and medications on time, etc.

    Anyway, so there's that. Her existing complications include hypertension, renal insufficiency, Charcot's joint Disease, Diabetic retinopathy and diabetic neuopathy, erosive esophagitis w/ ulcers. She was admitted with nausea, vomiting and diarhea, all of which was resolved after receiving an enema. She was diagnosed with gastroparesis. Soooooo,

    nursing diagnosis -- I DON'T KNOW! I am trying so hard to figure this out, I have all 4 books in front of me, and I can't figure this out. I know that it means "decreased gut motility", but I can't find that as a nursing diagnosis, so I know that can't be right to just write that in. Would it be nausea, vomiting or diarrhea? but which is most important to choose it to be the nursing diagnosis?

    Please, I don't want anyone to do my work, but if someone can help me, give me a little shove in the right direction, it will save me so much frustration. I thank you so much.
    Last edit by RNwannabeJEN on Feb 20, '03
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    About Jenn_RN

    Joined: Oct '02; Posts: 133


  3. by   Jenn_RN
    Alright, I am talking to myself, lol! Anyway, since a change in diet would be key and maybe the nursing diagnosis (since the anusea, vomiting and diahrea have subsided), would I use knowledge deficit related to nutrtion requirements of gastroparesis? See, I have no idea how to word it?
  4. by   Jenn_RN
    Is there a reason why no one is answering my post? I read a while back about a lot of you complaining of people asking others to do their work for them. I am not asking for that. I have already finsihed my care plan since posting this, but I wanted some insight, some guidance. Is this the wrong question to ask, an opinion on a nursing diagnosis? If so, please tell me and I won't ask for help anymore -- I have to say, I didn't think I was out of line, so if I am, please tell me so I don't make the mistake again. Thank you
  5. by   shudokan-RN
    some of us dont have to make up nursing diagnoses, we have to look them up, be patient
  6. by   memphispanda
    What diagnosis system are you using? The only one I am familiar with is NANDA.

    How many diagnoses are you looking for? Just one right now? If so, then you are looking for what is called the priority diagnosis. What is her most major problem right now? If the N/V have stopped, is there anything else going on that is causing her pain or that she is complaining of? If not, then knowledge deficit could be priority because it could cause the problem to occur again. You could try something like Knowledge deficit: diet related to new diagnosis of gastroparesis as evidenced by (whatever your evidence is).

    As far as not getting responses, you aren't giving it enough time! There wasn't even an hour from the time you posted to your third post. I hadn't even seen your first post, and I am sure others hadn't either.
  7. by   RNConnieF
    The goal of a Care Plan is to meet your pts. needs, as you define them (Diagnosis). The short version of this is:
    What is the problem? Diagnosis
    What makes this the problem? Related To
    How do I know this is the problem? As Evidenced By
    What nursing care do I need to provide to solve this problem? Implementation. Why do I want to do this? Rational for Implementation.
    How do I want this to end? Outcome How fast? Goal
    How do I know I did a good job nursing this pt? Evaluation.
    I start by getting my Diagnosis, Related To, and As Evidenced by. Then I jump to my Outcome. After I know where I want to go I can develop a plan to get there (Implementation) and why I am going to do these things (Rational). Now I do my short and long term goals and Evaluation. For your pt. it would look like this: Diagnosis: Self Care Deficit-Nutrition Less Than Body Requirements ,R/T Dietary Restrictions of Diabetes and Gastroparesis; AEB:1) Hospitalization for N/V, 2) Electrolyte Values (here list the abnormal values you have that are related to N/V), 3) Change in Normal Bowel Patterns. From here it's easy- what do you want to have happen? (Outcome) 1)Pt. tolerates kCal intake of 1500 calories/day (or whatever works for you)prior to d/c, 2) Electrolyte values return to pt's baseline, within 3 days, 3) Bowel function returns to pt's norm, prior to d/c, 4) Pt.verbalizes understanding of dietary restrictions, by end of shift, What do you have to do to make it happen? (Implementation) 1) Provide written diet education materials, (Rational: education is necessary to develop plan),2) Provide socialization during meals,(pt may eat better if meal time is a social experience, 3) Pt. participates in the development of a plan to meet nutritional needs after d/c, within 4 days. And so on, I think you get the idea. Now, go back and evaluate your interventions, all you have to do is go down your list of Outcomes and state either "Met" or "Unmet". If unmet you have to revise your outcome or intervention. Once you get the hang of it it's easy. Keep working on it, you'll get it.
  8. by   Jenn_RN
    See that's the thing I didn't get -- I was under the impression that in writing a careplan, you could not use a medical diagnosis. I came up with this:

    Diagnosis_ Nutrition:imbalanced, less than body requirements RT decreased gastric motility AEB nausea, vomiting, diarrhea.

    short term goal -- client will eat a proper diet for maintetenance of disease process (?) while in hospital, read literature on and discuss the importance of proper nutrition, and proper insulin administration.

    Nursing orders/interventions_(1)assess and monitor blood glucose levels (2)teach client proper nutrition per disease process(3)assess and monitor vital signs(4)teach client proper insulin administration as required by disease proccess

    I have rationales for each of those, with page numbers to corroborate my info.

    So how off base am I? It's my first time, so be gentle if I was WAAAAY off.

    (And I am sorry for spazzing about no one answering my post. Can you tell I am not used to feeling like I can't do something? )
  9. by   RNConnieF
    You can't use a medical diagnosis as part of your diagnosis- it HAS to be a nursing diagnosis. Some instructors won't let you use a medical diagnosis EVER, some are more reasonable-it depends. Your diagnosis is MUCH better than mine in not using a medical diagnosis. Sounds like you did a great job. Way to go.
  10. by   Jenn_RN
    Connie, are you serious, b/c I thought yours was WAY better! I was going to ask your permission in using the lab values aspect, but I wanted to ask, do nurses need dr persmission to draw labs, or is that something we can do independantly? Your short term goals were AWESOME, much better than what I could come up with. May I use a variation of what you offered me as an example? Thank you so much for your patience and help, I bet as I do thi snext time it'll come easier, and then easier still. (At least, that's what I am hoping for!!)
  11. by   Jenn_RN
    Oh, and one more thing (and i'll stop bugging you, lol). We are not allowed to do our careplans until after clinical. How in the world am I supposed to do these interventions when I am already gone? We do a clinical prep tool that is similar, where we identify the diagnosis, key problems, interventions, outcomes, etc, but we are not expected to formmulate a diagnosis until we do our careplan the night we get back from clinical. That does not make sense to me?????
  12. by   NurseShell
    The way we "get around" the medical diagnosis thing is by "specifying" our nursing diagnosis - using parentheses. So it would look like this:

    Imbalanced nutrituion: less than body requirement. R/T inability to ingest, digest, or absorb nutrients due to biological factors (nausea, vomiting, decreased gastric motility) AEB abdominal pain, diarrhea

    I know that's not exaclty it, but I hope it helps...last semester I wasn't using the specifications b/c they didn't say we could...now I have a teacher who is upset if we don't "personalize" the ND to each patient.
  13. by   NurseShell
    Originally posted by RNwannabeJEN
    Oh, and one more thing (and i'll stop bugging you, lol). We are not allowed to do our careplans until after clinical. How in the world am I supposed to do these interventions when I am already gone? We do a clinical prep tool that is similar, where we identify the diagnosis, key problems, interventions, outcomes, etc, but we are not expected to formmulate a diagnosis until we do our careplan the night we get back from clinical. That does not make sense to me?????
    I write what I did that day...I work what I did all day into my care plans...it works wonderfully!!
  14. by   RNConnieF
    One way to get around the no medical dx is to say R/T "disease , process". I'm pretty sure the decreased gastric motility would fly it's not a diagnosis. For diabetes you would have to say something about "ineffective metabolism of carbohydrates". It sounds silly but it works. As for interventions, you should be basing ALL your nursing care on a care plan, even if it's in your head, all the time. As you go on in the program you'll have to turn in your care plan at the end of the clinical day so start thinking now about using care plans in practice and not just as a paper that's due. It comes with practice, and I'm sure you're already doing it. When you first meet your diabetic pt. you know right away that diet teaching is going to be a priority-that's using a care plan. See, it's not as hard as it looks.