Help with care plan, pt discharged

[rhosekate93]

Hello Guys!...need some help in making a NCP for a client who has been discharged at the end of my shift. He is about 8 y/o with a Final Diagnosis of UTI with moderate dehydration. As for the Review of Systems, all of them are normal. Really need your help on this...:))

[Esme12, ASN, BSN, RN]

welcome to an! the largest online nursing community!

we are happy to help with homework but we won't do it for you. what do yiou have so far so i can see what you thought process is? what semester are you so i can better guide you? did you spend any time with this child? what were the child's complaints? remember your care plan is the plan of care for that patient. a recipe on what you need to think of, and do, for this patient. what did the child say? how would erickson growht and development effect what you need to do for this child and how would you care for them? what is a uti? how would you further prevent utis from occurring? what other considerations are there? what was assessment/interaction during your time with the child?

the biggest thing about a care plan is the assessment, of the patient. not just physical assessment......but what the patient says, feels, interacts with their environment/family. 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.

the medical diagnosis is the disease itself. it is what the patient has not necessarily what the patient needs. the medical diagnosis is what the patient has and 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.

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 them as a recipe to caring for your patient. your plan of care.

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:

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)
   

[NurseMaybeBaby]

Knowledge deficit

Fluid volume deficit

Risk for infection (invasive procedures)

Alteration in comfort (pain meds, IV sticks)

[nurseprnRN, BSN, RN]

it's generous of nursemaybebaby to give you some answers, even though we do try very hard not to do your homework for you, as my friend esme says above.

there are others that would be very appropriate for this child and his parent/guardian, and your instructor will be looking to see that you sought them. have you looked through your nanda-i 2012-2014, particularly at the urinary function, coping, safety, comfort, and role-related diagnoses? do any of them have defining characteristics found in your patient/family?

[NurseMaybeBaby]

I gave a few answers because I remember when I first started doing care plans, I had a hard time getting started. Once I had an appropriate diagnosis, I was able to formulate the care plan. The concept of a nursing diagnosis is difficult for new students so I was just trying to help. She still has a lot of work to do on her own even though I suggested a few things.

[Esme12, ASN, BSN, RN]

Absolutely.....they still have plenty of work even if given the correct diagnosis but, what I need to see is where does the help need to start. Where in the process is this particular student is having difficulty so I can lead them to the path to make them the best nurse they can be. Finding the nursing diagnosis is the vital part in becoming the best nurse you can be.

Learning to look at the patient and thinking.....What do I need to do for them first.....What is most important/necessary for this patient to care for them today and tomorrow.....How can I make it so they can go home faster......What do they need to know to better their health and treatment compliance......what do I need to do to achieve this goal.

Many Students make the mistake of only considering the medical diagnosis and not the patients needs. While the diagnosis is significant in the process it is not necessarily the best plan of care for this particular patient. Show me where to lead you and I will show you the way with flood lights.

[NICUmiiki, DNP, NP]

I'm so happy to know that I'll have such great resources to turn to for help when I get to that part of my education.