what would some good orems and nandas for my care plan?

Brighten · Mar 2, 2013

knowledge deficit of medication regimen

impaired skin or tissue integrity

risk for infection

theres alot my man

Esme12, ASN, BSN, RN · Mar 2, 2013

We are happy to help with homework but we will not do it for you. What do you have so far? What semester are you?

It is necessary to have a good care plan book. I use Aclkey. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

What care plan book do you have?

Care plans are all about the assessment.....of the patient. The is not enough information here for us to help. Tell me about your patient, What is your assessment? What do they NEED? What is their main complaint? What are their co-morbidities? How old is this patient? What is their base line? What meds are they on?

YOU MUST have a good care plan book with the NANDA diagnosis and it defining characteristics.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to 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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

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: ADPIE

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)

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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.

Thesesheet may help you out.....daytonite made them (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

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. Although your patient isn't real you do have information available.

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 is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

So tell me about your patient.......What do they need? What do they c/o? ? What is your assessment......What does this tell me about the patient? You ahve not provided enough information for us to help you.....

Priaz · Mar 2, 2013

my patient's is a 48 y/o hispanic admitted for "severe hyperglycemia with ketonuria", which i know are symptoms of DKA. He's a very positive patient and is very knowledgeable about his disease. He's not overweight, in fact, he is very thin. He is also an incomplete quadriplegic secondary to a GSW 23 years ago that affected his C5/C6 vertebrae, so he is paralyzed from the chest down. He has a colostomy bag, and many pressure ulcers. He is able to ambulate by wheelchair only. He knows he was on metformin for high blood sugar, but then his blood sugar got too low, so his doctor told him to stop taking it. He doesn't have a problem eating. He eats basically everything given to him since he doesn't like wasting food. He also uses an exercise bike 3x a week. I don't think knowledge deficit would be an effective nanda for him, because he seems to know a lot. What are my other options. I'm thinking risk for infection, since he has many pressure ulcers, but what else could i use?

nurseprnRN, BSN, RN · Mar 2, 2013

Big situation.

Pressure ulcers are caused by pressure, sure, but they don't heal often because of nutritional deficits and decreases in serum testosterone (needed for wound healing and tissue repair). Does that give you some ideas about what to search for in your NANDA-I 2012-2014? What nursing diagnosis would you check out to see if they had defining characteristics that included assessment data on pressure ulcers?

How do you know he knows enough about diabetes? If he just stopped taking his metformin (even if he says his doctor told him to...sounds unlikely to me, but hey) and was admitted with severe hyperglycemia, there's a lot he doesn't seem to know about self management. What does that suggest? How would you deal with that? (If your first need is to get more information, that's a good plan.)

What are some of the other common complications of diabetes? Does he have any assessment findings that indicate they could be occurring? What are they? What nursing diagnoses would involve those?

(hint: spinal cord injury patients are at increased risk of accelerated cardiovascular disease... what else happens as consequences of normal aging? how would diabetes affect those?)

Priaz · Mar 2, 2013

ohh... i never thought of it that way. Even if he does seem to know much about it, he still probably needs more teaching about it, since his blood sugar is still uncontrollable. It makes more sense now. Thank you all so much!

nurseprnRN, BSN, RN · Mar 2, 2013

Uncontrollable is one thing-- what common things can cause blood sugar to skyrocket besides od'ing on calories in untreated diabetes? You'll see these common things a lot in elders and disabled.

Uncontrolled is something else, and implies an act of omission. See why nurses have to think broadly?

Priaz · Mar 2, 2013

i do. thank you very much!

Esme12, ASN, BSN, RN · Mar 2, 2013

my patient's is a 48 y/o hispanic admitted for "severe hyperglycemia with ketonuria", which i know are symptoms of DKA. He's a very positive patient and is very knowledgeable about his disease. He's not overweight, in fact, he is very thin. He is also an incomplete quadriplegic secondary to a GSW 23 years ago that affected his C5/C6 vertebrae, so he is paralyzed from the chest down. He has a colostomy bag, and many pressure ulcers. He is able to ambulate by wheelchair only. He knows he was on metformin for high blood sugar, but then his blood sugar got too low, so his doctor told him to stop taking it. He doesn't have a problem eating. He eats basically everything given to him since he doesn't like wasting food. He also uses an exercise bike 3x a week. I don't think knowledge deficit would be an effective nanda for him, because he seems to know a lot. What are my other options. I'm thinking risk for infection, since he has many pressure ulcers, but what else could i use?

He also has a foley I'll bet.....so looking and this information what does this patient NEED? These are a few that I can think of......just with the information provided. Now use your NANDA/care plan book to see which diagnosis he fits and that you have evidence for to prove it's presence.

Ineffective self Health management

Impaired physical Mobility

Self Neglect

Imbalanced Nutrition: less than body requirements

neffective peripheral tissue Perfusion

Bathing Self-Care deficit

Impaired Skin integrity

Impaired Tissue integrity

Risk for unstable blood Glucose level

Risk for Electrolyte imbalance

Risk for Infection

The basis of OREMS philosophy is......

Self-care maintains wholeness.
Three Theories:
Theory of Self-Care
Theory of Self-Care Deficit
Theory of Nursing Systems
[*]Nursing Care:
Wholly compensatory (doing for the patient)
Partly compensatory (helping the patient do for himself or herself)
Supportive- educative (Helping patient to learn self care and emphasizing on the importance of nurses' role
http://currentnursing.com/nursing_theory/introduction.html

How does this apply to your patient who is an incomplete quad?