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Discussion

Heirarchy of Needs - Care Plan

Hey nurses,

I'm doing my first care plan! Yay! Kinda... I'm stuck on the Diagnosis. :sarcastic: I know how to use the Ackley book, NOC/NIC, etc.. to formulate the rest. But I just "can't" pick a diagnosis!

It's about a patient who is "Knowledge Deficit" of his disease (Why test glucose - my doctor knows the numbers? I eat a lot of carbs - but no sugar so why am I diabetic?) etc..

BUT

Because he eats so much carbs, I also see the "Imbalanced Nutrition: More Than Body Requirements"

SO

Couldn't it possibly be "Ineffective Self-Health Management" r/t Deficient Knowledge of Disease Care or something (He was told to lose weight and did not comply, however he says he "trys" to lose weight but can't)?

I'm so confused. I used the Hierarchy of Needs and saw the Nutrition Imbalance diagnosis "should" come first, but then the Ackley definition doesn't really match up, so from what "I" notice, the Deficient Knowledge definition sounds more like him - which falls LAST on the Hierarchy?

How do you figure out Top Priority when you're defining characteristics don't match to the "top" diagnosis? :down:

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    • Featured Replies

    • Expert

    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 from our Daytonite

    1. 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)

    2. 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)

    3. Planning
      (write measurable goals/outcomes and nursing interventions)

    4. Implementation
      (initiate the care plan)

    5. 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.

    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.

    Another member GrnTea say this best......

    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

    "Related to" means "caused by," not something else.

    Now tell me abouot your patient so we can start from scratch
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    You also cannot rely on a "care plan handbook" for accurate nursing diagnoses. Why? Because there is only one definitive source for them, and that's the NANDA-I 2012-2014. Because NANDA-I is understandably unwilling to allow anyone else to quote their entire work wholesale, other authors either paraphrase or use older editions which may (and do) include nursing diagnoses that have been withdrawn for lack of (wait for it!)...... EVIDENCE.

    So you go to Amazon and get this little book, and you flip to page 175, and there's Imbalanced nutrition, more than body requirements. Now here's the thing: Every nursing diagnosis has a finite list (not infinite) of defining characteristics and related (which means causative) factors. If your patient doesn't meet those criteria, you cannot cannot cannot make (not "choose") that diagnosis.

    So, in this case, the defining characteristics are:

    * Concentrating food intake at the end of the day

    * dysfunctional eating pattern (e.g., pairing food with other activities)

    * eating in response to external cues (e.g., time of day, social situation)

    * eating in response to internal cues other than hunger (e.g., anxiety)

    * sedentary lifestyle

    * triceps skin fold greater than 15 mm in men, greater than 25 mm in women

    * weight 20% over ideal for height and frame

    Related factors (this means, what caused this?)

    * Excessive intake in relation to metabolic need

    * excessive intake in relation to physical activity (caloric expenditure)

    I don't see anything in your description this patient that meets any of these things. Maybe he does, but you haven't told me if you assessed that. Therefore, he does not meet the definition, and you cannot make this nursing diagnosis.

    So let's look at "ineffective health management." There isn't actually a nursing diagnosis by that name. So you can't make that diagnosis either.

    You could look at "ineffective health maintenance," page 157. This is defined as, "inability to identify, manage, and/or seek out help to maintain health"

    Defining characteristics

    * Demonstrated lack of adaptive behaviors to environmental changes

    * demonstrated lack of knowledge about basic health practices

    * history of lack of health seeking behavior

    * inability to take responsibility for meeting basic health practices

    * impairment of personal support systems

    * lack of expressed interest in improving health behaviors

    Related factors

    * cognitive impairment

    * complicated grieving

    * deficient communication skills

    * diminished fine motor skills or gross motor skills

    * inability to make appropriate judgments

    * ineffective family coping

    * ineffective individual coping

    * insufficient resources (e.g., equipment, finances)

    * lack of fine or gross motor skills

    * perceptual impairment

    * spiritual distress

    * unachieved developmental tasks

    Now, does this sound like your guy? Remember, you need to have assessed at least one defining characteristic, and at least one related factor.

    Now, there is "ineffective self - health management," on page 161. This sounds a little bit more like your guy. Definition is, "pattern of integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals."

    Defining characteristics include such things as failure to include treatment regimens into daily living, failure to take action to reduce risk factors, ineffective choices and daily living for meeting health goals, all of which sound like your guy to me. It also includes reporting desire to manage the illness and reporting difficulty with prescribed regimens. You can ask him about that.

    Related factors includes a pretty long list, but deficient knowledge is among them. He may have others.

    See, isn't that cool? Isn't that exactly what you needed?

    So I would encourage you to go to Amazon and pick up this book. It's 29 bucks with free 2 day delivery for students, or 25 bucks with instant delivery to your iPad or Kindle.

    When you get it, look through it and put little tabbies on the front of each section and label them. They include health promotion, nutrition, elimination and exchange, activity and rest, perception and cognition, self perception, role, sex, coping and stress, life principles, safety, comfort, and growth and development. Now, when you think you have an idea of some kind of nursing diagnosis, you go and flip through those pages. When you find one that looks about right, you look at the definition, defining characteristics, and related factors. If these match your assessment of your patient, bingo! Congratulations! You made a nursing diagnosis! :anpom: If not, look around some more. YOu know what? You can do this on assigned patients before you assess them, not to make nursing diagnoses, because, as you now know, you can't make a nursing diagnosis without actual data, but to give you an idea of what kind of assessments might be smart to make when you go into clinical tomorrow.

    I promise you that this is gonna save your bacon in nursing school, and you'll learn to think like a nurse a lot faster than your classmates. Although you could share this hint, and you can all blow your faculty away..;)

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    • Author

    Thank you guys. I understand the ADPIE and diagnosis based on evidence by the characteristics from the patient, and the nursing vs medical diagnosis. I also read a lot of other posts too and read those comments. I appreciate them though, as some may have not seen them so your just looking out ;) I also have the NANDA I (NIC/NOC) book I utilized into my practice. I have all the bases covered on everything you guys explained - I just don't think my question was very clear, it's all this stress :no: lol I was wondering about characteristics matching qualities of other diagnoses lower on the priority list, as opposed to one characteristic of a higher priority. The teacher got back to us all in email today, and clarified (always go with highest priority, even if it only has *one* characteristic and a lower one matches to a *T*). Thanks!

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    • Expert

    It is difficult to know where someone is in the process. You need to prioritize according to the ABC's. What would kill the patient first. Maslows is a guideline to get you started.

    For this example the one that fits best is imbalanced nutrition to manage his disease...without this his disease can kill him.' On a side note...people with insulin resistance it is extremely difficult to lose weight.

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    • Author

    Thats what I ended up putting for my diagnosis. Even though, one teacher said "Education" and our other said "Nutrition", I went with priorities. Just waiting on my grade to find out if I was right now! Thanks! :)

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    I agree with GrnTea but my conclusion was a little more short form. I have been taught and come to understand the Imbalanced Nutrition diagnosis as too many calories for expenditure (the "less than" diagnosis is a little different, however). Also, to say that the pt simply eats too many carbs is a judgement you're making that may not have as much evidence on your side and would be a judgement better made by a nutritionist. If he says all he eats is pasta and white bread, that's one thing, but he still should be able to control that with his insulin. He states he isn't checking his glucose properly, however, and that is a serious problem. If he understands his doctor to "know his sugar levels" that's not good. These are all subjective data you have in your assessment, along with consistently high BG checks and an A1C over 7% that support the education Dx.

    As a side note, if his protein labs were low due to "kwashiorkor-type" malnutrition (kind of a long shot because if his protein levels are low it is likely due to a different physiological reason and not due to not eating enough protein) then maybe, just maybe, the Imbalanced Nutrition Dx could work.

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    • Author

    Hey La Chica,

    His profile said he ate 2 cups of pasta with dinner, plus two slices of bread, and for lunch he ate two slices of toast with olive oil. His A1C was never

    I still don't know what kwashiorkor-type malnutrition is, I'm only in my first month of my first semester as a nursing student, so hopefully they didn't expect anything like that or anything crazy in depth yet, but you never know :eek: lol

    Thank you for the help too!

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    • Expert

    The thing is is this all you think is important from your assessment?

    Were his glucose under control? Whay was he in the hospital? What was his main complaint? What is your assessment of the patient.

  • Quote
    Hey La Chica,

    His profile said he ate 2 cups of pasta with dinner, plus two slices of bread, and for lunch he ate two slices of toast with olive oil. His A1C was never

    I still don't know what kwashiorkor-type malnutrition is, I'm only in my first month of my first semester as a nursing student, so hopefully they didn't expect anything like that or anything crazy in depth yet, but you never know :eek: lol

    Thank you for the help too!

    I don't know how they do it for your program but kwashiorkor and marasmus malnutrition types are something we were taught in our first quarter. However, I mentioned them only as a technicality because these things you are really unlikely to see in an adult male diabetic in this country (the US).

    But you're right, you can find so many problems with one patient that it's hard to just pick a few (were you only doing one Dx? in my program we have 3 - 2 priority phys and 1 priority psychosocial) when in reality your plan of care is going to touch on all aspects. At my first clinical site our pt charts generated Dxs, interventions, goals and outcomes that were basically just check boxes at time of discharge (so, yeah, nursing care plans aren't really your number one priority once you actually start working -- at least not the way you are being taught them). Also, consider answering the questions posed in the post above me.

    Anyway, good luck! Embrace everything that comes at you - good and bad!

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