Help with Care Plan

Kuriin, BSN, RN · Oct 17, 2013

If the patient's chief complaint is the nurse's priority, then that's what you write about in the diagnosis. In the beginning of the diagnosis book has a list of actual medical diagnoses and suggestions what you can write about.

For example, cancer:

Ineffective coping r/t prolonged disease aeb patient's progressive cancer.

What's your patient's chief complaint?

http://1.bp.blogspot.com/_E4VRTHYYpkY/S88l7lYpcwI/AAAAAAAAFPY/2ZG9owecr9c/s1600/deficient+knowledge.JPG

Esme12, ASN, BSN, RN · Oct 17, 2013

I am working on a care plan for my nursing class, but my peers and I are a little confused, and the professors are currently "booked" with too many meetings. I am wondering if anyone knows of any examples we could look at, or possibly assist us with what data needs to be put on the care plan.
There are 3 full pages of data... both subjective and objective, that are all important. However, we should only write down the data that pertains to his chief complaint? It's a little confusing and certainly overwhelming. If someone is willing to help and give their 2 cents, I can post the assignment itself.
I know these assignments all differ, for ours, we need to write the data, diagnosis, short term and long term goals, intervention, rationale, and evaluation.

Tell me assignment....give me the scenario.

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

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.

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.

tell me about this patient.

nurseprnRN, BSN, RN · Oct 17, 2013

If the patient's chief complaint is the nurse's priority, then that's what you write about in the diagnosis. In the beginning of the diagnosis book has a list of actual medical diagnoses and suggestions what you can write about.
For example, cancer:
Ineffective coping r/t prolonged disease aeb patient's progressive cancer.
/QUOTE]
If you look at the nursing diagnosis of "ineffective coping," p. 348 in your NANDA-I 2012-2014, for which there is no substitute, there is no related factor of "prolonged illness," so you cannot use that. It's really important for students to get clear from the beginning that you can't just make up a r/t factor because it sounds good to you. Nursing diagnosis has the power it has because it is evidence-based; you can, and must, use what's in the NANDA-I list.
(Just the fact of the patient having cancer doesn't mean he isn't coping effectively, either, or that if he isn't coping effectively then the cancer is the reason for it. You'd need patient-specific indicators of ineffective coping, such as "Pt states, 'I just don't know how to deal with all the weakness from the chemo,' " or, "I can't go to church while I'm on isolation and I miss that support." Or something like that.)

A lot of people will tell you that you cannot use a medical diagnosis as a cause for a nursing diagnosis, but that's wrong. However, this is the first time that I think I am hearing that someone thinks you must use a medical diagnosis as a basis for nursing diagnosis. That is not generally true.

See, you do not want to fall into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your nursing skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.
Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.
You are responsible for delivering some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.
This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.
You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood."
Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.
There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Every nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.
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. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)
To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!
If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:
1, health promotion (teaching, immunization....)
2, nutrition (ingestion, metabolism, hydration....)
3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
5, perception and cognition (attention, orientation, cognition, communication...)
6, self-perception (hopelessness, loneliness, self-esteem, body image...)
7, role (family relationships, parenting, social interaction...)
8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
10, life principles (hope, spiritual, decisional conflict, nonadherence...)
11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
12, comfort (physical, environmental, social...)
13, growth and development (disproportionate, delayed...)
Now, if you are ever tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

nurseprnRN, BSN, RN · Oct 17, 2013

Oooh, and I just got a great book for interventions. The Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon.

It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Kuriin, BSN, RN · Oct 17, 2013

Oi, GrnTea, it was an example of a diagnosis in the front of the book. Not necessarily the one you would use for someone with cancer.

edit:

http://www.amazon.com/Nursing-Diagnosis-Handbook-Evidence-Based-Planning/dp/0323085490/ref=sr_1_2?ie=UTF8&qid=1382050058&sr=8-2&keywords=Nursing+Diagnosis

That book has examples you could use on actual medical diagnoses.

nurseprnRN, BSN, RN · Oct 17, 2013

Oi, GrnTea, it was an example of a diagnosis in the front of the book. Not necessarily the one you would use for someone with cancer.
edit:
Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 10e: Betty J. Ackley MSN EdS RN, Gail B. Ladwig MSN RN: 9780323085496: Amazon.com: Books
That book has examples you could use on actual medical diagnoses.

You might see any number of nursing diagnoses in patients with those medical diagnoses, but that doesn't relieve you of the responsibility of identifying the defining characteristics in the NANDA-I taxonomy to make a nursing diagnosis in the actual individual before you. Sorry I didn't make myself clear on that.

Jenngirl34RN · Oct 18, 2013

So the way that my instructor explained it to my class is that in each scenario she gives us there will be far, far more nursing diagnoses than you are required to include in our assignments...I got the sense that it was partly so we learn how to figure out how to sort through and make sense of all that data, and partly because the instructor doesn't want to read 28 care plans that are all exactly the same. We make cluster maps of data as sort of a rough draft, and choose our NANDA diagnoses by reading the definition of each diagnosis and comparing our data clusters to the defining characteristics. While we do acknowledge the medical diagnosis at the top of the page, it in itself is not used to generate the nursing diagnoses. We base those off of the signs and symptoms the patient is exhibiting, whether or not they are directly related to the medical dx. Also, she said that the chief complaint is not always our first priority, although we make it that if we can. We use Maslow's Hierarchy of Needs to prioritize, with the ABCs as top priorities always.

Hope that helps! I am still pretty new at doing these too, but I think I am getting the hang of them now, and I am sure you will too!

Jaredjdb · Oct 24, 2013

Thank you everyone!

I'm sorry I didn't respond sooner, Allnurses no longer had my setting to e-mail me when someone replies!

I understand a lot of what was said, and I am glad that most of you stressed the importance of those things. What I found (and still find) difficult is choosing the right diagnoses, when like Jenngirl34 said, there can be a lot.

Long story short, my client had breathing difficulties and his chief complaint was that it was hard to catch his breath. He was experiencing some sharp pain on inhalation, dyspnea on exertion, pale skin, oxygen saturation of 90%, etc. My primary diagnosis was between irregular breathing pattern and what I ultimately chose: Impaired gas exchange r/t altered oxygen supply as evidenced by oxygen saturation of 90%.

My other issue was the the signs and symptoms, which there were multiple that pointed to the patient's inability to breath properly and provide enough oxygen, but my professor said to only say one?

Does that seem like a proper ND in and of itself? Or does it not even make sense?

Esme12, ASN, BSN, RN · Oct 24, 2013

Do you have a current care plan book?

nurseprnRN, BSN, RN · Oct 24, 2013

Long story short, my client had breathing difficulties and his chief complaint was that it was hard to catch his breath. He was experiencing some sharp pain on inhalation, dyspnea on exertion, pale skin, oxygen saturation of 90%, etc. My primary diagnosis was between irregular breathing pattern and what I ultimately chose: Impaired gas exchange r/t altered oxygen supply as evidenced by oxygen saturation of 90%.
My other issue was the the signs and symptoms, which there were multiple that pointed to the patient's inability to breath properly and provide enough oxygen, but my professor said to only say one?
Does that seem like a proper ND in and of itself? Or does it not even make sense?

Alas, you are falling into the trap of choosing a sexy-sounding nursing diagnosis from a list and not verifying the cause and defining characteristics from the only reference there is for them, the NANDA-I 2012-2014. You don't get to make them up. Nobody does.

The nursing diagnosis of "Impaired gas exchange" has only two related (causative) factors, and neither of them is "reduced oxygen supply." You cannot use that. You patient very likely has one of the two approved ones, but you have to show that you know which one. As for "as evidenced by," some of your choices are "abnormal arterial blood gases" and "hypoxemia", so you can use those (if they apply-- there are others, many others), and then say, for example, "... evidenced by hypoxemia (SpO2 = 90%)."

Get your NANDA-I 2012-2014 from Amazon for $29, free two day delivery, and instant delivery to a Kindle for $24.

Questions?

Jaredjdb · Oct 24, 2013

Yes, I used it. I don't remember the name off the top of my head though.