Are you scratching your head or are you maybe even ready to tear your hair out over how to come up with care plans? Here are some words of wisdom from our own beloved Daytonite.
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.
How does a doctor diagnose?
He/she does (hopefully) a thorough medical history and physical examination first. Surprise! We do that too! It's part of step #1 of the nursing process. Only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. Each medical diagnosis has a defined list of symptoms that the patient's illness must match. Another surprise! We do that too! We call it "critical thinking and it's part of step #2 of the nursing process. The NANDA taxonomy lists the symptoms that go with each nursing diagnosis.
Steps of the Nursing Process:
Assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)
Now, listen up, because what I am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. The nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. One of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems. Why? Because as a working RN, you will be using that method many times a day at work to resolve all kinds of issues and minor riddles that will present themselves. That is what you are going to be paid to do. Most of the time you will do this critical thinking process in your head. For a care plan you have to commit your thinking process to paper. And in case you and any others reading this are wondering why in the blazes you are being forced to learn how to do these care plans, here's one very good and real world reason: because there is a federal law that mandates that every hospital that accepts medicare and medicaid payments for patients must include a written nursing care plan in every inpatient's chart whether the patient is a medicare/medicaid patient or not. If they don't, huge fines are assessed against the facility.
You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids.
Simple Example
Steps One - Five
You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "what's wrong?" you're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it. A huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. What you have just done is step #1 of the nursing process--performed an assessment.
You determine that you have a flat tire. You have just done step #2 of the nursing process--made a diagnosis.
The little squirrel starts running like crazy in the wheel up in your brain. "What do I do?," you are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. Good thing you took that class in how to do simple maintenance and repairs on a car! You have just done step #3 of the nursing process--planning (developed a goal and intervention).
You get the jack and spare tire out of the trunk, roll up your sleeves and get to work. You have just done step #4 of the nursing process--implementation of the plan.
After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive. Good. Everything seems fine. The spare tire seems to be OK and off you go and on your way. You have just done step #5 of the nursing process--evaluation (determined if your goal was met).
Can you relate to that? That's about as simple as I can reduce the nursing process to. But, you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.
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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. At all times. And that is within the spirit of step #1 of this whole 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. 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.
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 (ex: activity intolerance) is actually a shorthand label for the patient problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every NANDA nursing diagnosis has a definition).
Definition: insufficient physiological or psychological energy to endure or complete required or desired daily activities
(does this sound like your patient's problem?)
Defining Characteristics (symptoms): abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness
Related Factors (etiology): bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle.
I've just listed above all the NANDA information on the diagnosis of activity intolerance from the taxonomy. Only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.
In order to choose nursing diagnoses, you also need to have some sort of nursing diagnosis reference. There is some free information on the internet but it is limited to about 75 of the most commonly used nursing diagnoses.
One more thing...
Care Plan Reality
Nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. They are all linked together with each other to form a nice related circle of cause and effect.
You really shouldn't focus too much time on the nursing diagnoses. Most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. The nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.
Yes, I would report that under subjective data. Pt did refuse to answer right, even though they were capable of answering? If so, then yes I would put that pt refused to answer any questions. Although subjective data helps us as far as pain, complaints, how long, where, etc, if you have the chart information that will have to do. Can't make things up so you chart only facts even on care plans.
Hope that helps a little.
of course that helps! i would never lie about what patients stated or not stated..i was looking for an appropriate intervention a far as what the instructor would like to see in the subject area if the patient was not cooperative in that area....
got a another question--when you initially type out the word ex. cerebral vascular accident (CVA), is this caps from this point on???? or is it cerebral vascular accident (cva)...."the CT scan revealed evolving CVA...."
A care plan is based on the patient's problem and needs, not on their medical diagnosis. Did you go to the ultrasound with the patient? It took the whole clinical time that you had him? Hard to believe. A renal ultrasound takes all of 15-20 minutes to perform. I've had 2 myself. How long were you in clinical with this patient? What went on the minus the 15-20 minutes that the patient wasn't being ultrasound'. Did you talk to him? Assess him? Take a long break?[/quote
Unfortunately I wasn't able to go down to the scan with him. I did do a brief assessment, on him while I could because he didn't even eat breakfast so when he got back the first thing he did was eat, well sort of cause all he did was drink an 12oz cranberry juice, coffee, and a cup of water. It was wierd because from 7am-8am our instructor had us "dissect" the chart and get all of our patient info. So we didn't have like a day or whatever to have a plan in place so I only went off what the nurses and the doctors wrote in his chart. Oh and I stated he went to ultrasound, but actually he went for a Retropertineal Echogram, would that take longer?
Specializes in med/surg, telemetry, IV therapy, mgmt.
butterfly3001 said:
unfortunately I wasn't able to go down to the scan with him. I did do a brief assessment, on him while I could because he didn't even eat breakfast so when he got back the first thing he did was eat, well sort of cause all he did was drink an 12oz cranberry juice, coffee, and a cup of water. it was wierd because from 7am-8am our instructor had us "dissect" the chart and get all of our patient info. so we didn't have like a day or whatever to have a plan in place so I only went off what the nurses and the doctors wrote in his chart. oh and I stated he went to ultrasound, but actually he went for a retropertineal echogram, would that take longer?
what information did you get from the chart, particularly from the doctor's history and physical and his progress notes? that information, which is a big part of assessment, is extremely helpful in coming to nursing diagnoses. you will probably find the evidence for your patient's nursing diagnoses in that information that you copied down.
assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology). assessment involves:
a physical assessment of the patient
assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
then, 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)
what information did you get from the chart, particularly from the doctor's history and physical and his progress notes? that information, which is a big part of assessment, is extremely helpful in coming to nursing diagnoses. you will probably find the evidence for your patient's nursing diagnoses in that information that you copied down.
assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology). assessment involves:
a physical assessment of the patient
assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
then, 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)
well he came in complaining of a "burning" sensation when urinating and also pressure on his lower abdomen. he voided on 25mls. so the nurse performed a bladder scan and found >900mls in the bladder. in the h&p the doctors noted that his creatnine and bun levels were elevated. creatnine was 9.8 and bun 156. he had signs of edema but it was resolved by the time I came in which was two days after his admission. pt denied any urgency or frequency changes but did note that he had dribbling and a "weak" stream. would you think impaired urinary elimination would be appropriate. also his potassium was elevated 5.8. thanks for your help
Specializes in med/surg, telemetry, IV therapy, mgmt.
well he came in complaining of a "burning" sensation when urinating and also pressure on his lower abdomen. he voided on 25mls. so the nurse performed a bladder scan and found >900mls in the bladder. in the h&p the doctors noted that his creatnine and bun levels were elevated. creatnine was 9.8 and bun 156. he had signs of edema but it was resolved by the time i came in which was two days after his admission. pt denied any urgency or frequency changes but did note that he had dribbling and a "weak" stream. would you think impaired urinary elimination would be appropriate. also his potassium was elevated 5.8. thanks for your help
ok! this is information that you can work with. the voiding of 25 mls was small voiding as the patient was trying to void around an obstructed urethra. "the nurse performed a bladder scan and found >900mls in the bladder" means he is retaining urine and not emptying his bladder completely. these scans are performed after the patient has voided to see how much urine is still in the bladder and indicates residual urine. the correct nursing diagnosis for this is urinary retention r/t swelling [this is based on what the information you supplied--the swelling is causing blockage of the urine] aeb 900mls of urine remaining in the bladder after voiding, small voidings and dribbling. you can read more about this diagnosis on this webpage: urinary retention without this catheter this patient would not be able to empty his bladder and void efficiently.
the elevated bun and creatinine probably indicate renal damage, but there are no nursing diagnoses for that. unless you have patient responses of the elevated bun, creatinine and potassium (i.e. bradycardia, hypotension, muscle cramps, paresthesias), there is probably nothing you can diagnose in relation to them.
with a foley catheter you can use risk forinfection r/t invasive procedure [uti or urosepsis]
ok! this is information that you can work with. the voiding of 25 mls was small voiding as the patient was trying to void around an obstructed urethra. "the nurse performed a bladder scan and found >900mls in the bladder" means he is retaining urine and not emptying his bladder completely. these scans are performed after the patient has voided to see how much urine is still in the bladder and indicates residual urine. the correct nursing diagnosis for this is urinary retention r/t swelling [this is based on what the information you supplied--the swelling is causing blockage of the urine] aeb 900mls of urine remaining in the bladder after voiding, small voidings and dribbling. you can read more about this diagnosis on this webpage: urinary retention without this catheter this patient would not be able to empty his bladder and void efficiently.
the elevated bun and creatinine probably indicate renal damage, but there are no nursing diagnoses for that. unless you have patient responses of the elevated bun, creatinine and potassium (i.e. bradycardia, hypotension, muscle cramps, paresthesias), there is probably nothing you can diagnose in relation to them.
with a foley catheter you can use risk forinfection r/t invasive procedure [uti or urosepsis]
okay, awesome that works thanks so much. two more quick questions i also have two questions that ask how the patients diagnosis and hospitalization would affect him spiritually and psychologically. he didn't express any anxiety to me or seem sad or angry. also he is 89 if i didn't mention that. so at this point would i just write what things about it could possibly make him anxious since i didn't see any. thanks for your help you're wonderful!!!!!!!!!!!!!!:redbeathe and thank you for the link as well.
Specializes in med/surg, telemetry, IV therapy, mgmt.
Okay, awesome that works thanks so much. Two more quick questions I also have two questions that ask how the patients diagnosis and hospitalization would affect him spiritually and psychologically. He didn't express any anxiety to me or seem sad or angry. Also he is 89 if I didn't mention that. So at this point would i just write what things about it could possibly make him anxious since I didn't see any. Thanks for your help you're wonderful!!!!!!!!!!!!!!:redbeathe And thank you for the link as well.
I have no answer for you. You need to remember to ask and look for those ques with the next patient.
My problem is with Evaluations. I am in clinicals 2 days a week and when I dx something and elaborate it in the care plan, I can never seem to get good Eval criteria. For example, I am caring for a terminally ill man with CHF. DX: Fluid Volume Excess r/t CHF. This is something that will not be rectified and grand improvement of his edema is unlikely over my 2 days. How do I come up with evals? I am sooooo confused!
Specializes in med/surg, telemetry, IV therapy, mgmt.
My problem is with Evaluations. I am in clinicals 2 days a week and when I dx something and elaborate it in the care plan, I can never seem to get good Eval criteria. For example, I am caring for a terminally ill man with CHF. DX: Fluid Volume Excess r/t CHF. This is something that will not be rectified and grand improvement of his edema is unlikely over my 2 days. How do I come up with evals? I am sooooo confused!
--Thanks:banghead:
Your goals, then, must take that into account. What improvements do you expect to see as a result of your interventions over your 2 days with the patient? You may not see a "grand" improvement of edema, but "some" resolution of it. How can that be measured? It depends on your interventions. Perhaps by doing daily circumferences of the patient's lower legs? Or, how about doing daily weight? As the edema lessens the circumference of the lower legs will decrease although the edema has not completely resolved. Another way is with daily weights. As fluid is released from the body, weight declines. After 2 days, the patient should have lost ___ pounds of weight or ___ inches of circumference in the lower extremity. These are measurable goals that you can evaluate and based upon interventions you would be performing.
I just finished my first practice care and have recieved my feedback. I now have to do a comprehensive care plan for a grade but I was marked off for not correctly identifing my primary secondary or tertiary interventions.
My practice care plan was a 34 y/o gentleman who was 4 days post chest trauma from being run over by a car. This patient was supposed to go home the day that he was assigned to me. After assessing him that morning I was supicious for PE and it turned out I was correct. SO..alot of things happened quickly and he was transferred to the ICU before the end of my shift.
I used nursing diagnosis such as Impaired gas exchange, risk for disuse syndrome (which my instructor was happy with) but I don't understand how to rate the interventions that I used which were related to the nursing diagnosises.
Could anyone help me understand or give me some examples for the "staging" of the interventions.
Specializes in med/surg, telemetry, IV therapy, mgmt.
I just finished my first practice care and have recieved my feedback. I now have to do a comprehensive care plan for a grade but I was marked off for not correctly identifing my primary secondary or tertiary interventions.
My practice care plan was a 34 y/o gentleman who was 4 days post chest trauma from being run over by a car. This patient was supposed to go home the day that he was assigned to me. After assessing him that morning I was supicious for PE and it turned out I was correct. SO..alot of things happened quickly and he was transferred to the ICU before the end of my shift.
I used nursing diagnosis such as Impaired gas exchange, risk for disuse syndrome (which my instructor was happy with) but I don't understand how to rate the interventions that I used which were related to the nursing diagnosises.
Could anyone help me understand or give me some examples for the "staging" of the interventions.
Thanks
I am not familiar with the "staging" of interventions into primary, secondary and tertiary. I have an idea of how it could be accomplished. It is something that I am sure your instructors would have discussed with your class and given instructions on. Would you mind listing the directions on that please? Then, I will need to see at least one set of your interventions from one of your nursing diagnoses so I can use them to explain how to classify them.
WAWA TO GO
11 Posts
of course that helps! i would never lie about what patients stated or not stated..i was looking for an appropriate intervention a far as what the instructor would like to see in the subject area if the patient was not cooperative in that area....
got a another question--when you initially type out the word ex. cerebral vascular accident (CVA), is this caps from this point on???? or is it cerebral vascular accident (cva)...."the CT scan revealed evolving CVA...."
:typing