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.
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]
daytonite:
i recived my npr back because my instructor said one of my client goals isn't appropriate. i wrote " the client will void at least 120ml by 11am on 11-03-08. she said that he has a foley so that i can't write void and that i should concentrate more on managment of the foley. so with that being said i looked in my npr and i am leaning toward writing. i don't even no where to begin. i don't want you to answer for me just some kind of guidance please on what i should focus on as far as the foley goes. thank you
Specializes in med/surg, telemetry, IV therapy, mgmt.
DAYTONITE:
I recived my NPR back because my instructor said one of my client goals isn't appropriate. I wrote " The client will void at least 120mL by 11am on 11-03-08. She said that he has a foley so that I can't write void and that I should concentrate more on managment of the foley. So with that being said I looked in my NPR and I am leaning toward writing. I don't even no where to begin. I don't want you to answer for me just some kind of guidance please on what I should focus on as far as the foley goes. Thank you
Rather than "void" write The client will have a urine output of 120 mL by 11 am on 11-03-08. Is that what you wanted to know? Otherwise, look up the basic care of a foley catheter in a fundamentals book.
Specializes in med/surg, telemetry, IV therapy, mgmt.
can you please help me formulate a diagnosis for pregnant women? ahm, it should be about wellness and readiness..thanks!
Yes, I can do that. First, you need to list out the assessment information you collected because it becomes the foundation of any nursing diagnoses that you will eventually choose. When you were questioning her what kinds of things did you ask her about her health and the baby's health? What ADL (activities of daily living) subjects, or areas, did she indicate she would like to know more about?
I am a second year nursing student having difficulty writing a care plan. I had a 83 year old client who had a fall and was anemic. She had guiac stools and recieved a blood transfusion on the day I cared for her. her only other hx was hypothyroidism which was controlled by medications, hypertension which was controlled by medications, hyperlipidemia and osteoarthritis. She recieved 2 units of packed RBCs while under my care...her labs showed the anemia but I do not know what nursing diagnoses to use. I need 3. I think Risk for Falls should be one along with Caregiver Role Strain...she has some forgetfulness but still cooks and cleans her large home for her husband and cooks and bakes for her two sons who live down the street. She is weak and fatigued, anyone with advice it would be much appreciated....I was looking for a fluid imbalance but just cant seem to figure it out...thanks
I am not sure, but it seems you are to reply to threads already established..I am a second semester nursing student and for my Med-Surge class we are to develop a nursing care plan which includes 4 nursing dx with a concept map. I have completed the care plan but I did have a hard time especially with one dx of "ineffective renal tissue perfusion r/t renal insufficiency AEB elevation in BUN/Creatinine RAtio's. I will paste my care plan and if anyone can give me any input it would be greatly appreciated. Sorry its kind of long but any input woudl be great to see if I am on the right track.
my patient was admitted with : altered mental status,fever, chills, back pain.
Hx: Diabetes type 2,COPD,HTN,Spinal Osteomyelitis,Sleep apnea, Renal Insuff.
He is receiving treatments via hyperbaric chamber on a daily basis.
Labs: Bun-37H,
Creatinine-1.7H
RBC-4.06L,HGB-12.0L
Pain
Rated 10/10 located on his back from spinal osteomyeltis, and sacral/coccyx area from wound
-Agitated
-Facial grimace with activity
patient had a fever, chills,a positive sputum culture, with productive cough,fatigued, and the spinal osteomyelitis. Patient has a bed sore as well on his sacral/coccyx area appears to be red in color, no blanching, no discharge.
CARE Plan:
Nursing DX
Ineffective renal tissue perfusion R/T renal insufficiency AEB elevation in BUN/Creatinine ratio
Outcomes
-Client will maintain optimal tissue perfusion to vital organs ensured by presence of strong peripheral pulses, absence of respiratory distress, absence of chest pain, adequate urine output while on unit.
-Client will remain free of peripheral/pulmonary edema while in hospital
-Client will verbalize knowledge of treatment regiment, including medications and their actions and possible side effects while in hospital.
Interventions
-Monitor strict I&O's
-Monitor labs, notify M.D. of any changes-Assess for signs of decreased tissue perfusion I.e. weak/absent pulses, edema, cool extremities, mottling, prolonged capillary refill, tachycardia, hypotension, and tachypnea.
Evaluation
-B/P remained within acceptable parameters: 126/79-128/80
-Pulses present in all locations, no edema found, lungs clear to auscultation, capillary refill
-Client able to recognize medications administered and verbalizes actions/side effects.
Nursing Dx
Impaired tissue integrity R/T pressure, altered circulation AEB damaged integumentary tissue to sacral/coccyx area
Outcomes
-Client will report any altered sensation/pain at sight of tissue impairment while on unit
-Client will demonstrate understanding of plan to heal tissue/prevent injury by discharge
-Client will describe measures to protect and heal the tissue, including would care prior to discharge
Interventions
-Monitor status of skin around wound, assess blanching. Monitor client's skin care practices, noting type of soap used, temperature of water, and frequency of skin cleaning
-Don't position client on site of impaired tissue integrity
-Assess nutritional status
-Reposition client every 2 hours
Evaluation
-Client able to readjust position independently, and was doing so as necessary in 2 hour increments
-Client consuming 100% of meals offered
-Sacral/Coccyx area site inspected, redness present, no swelling, abrasion like in appearance, no discharge noted.
Nursing Dx
Risk for further infection R/T inadequate primary defenses (broken skin), tissue destruction, and spinal osteomyelitis.
Outcomes
-Client WBC will remain within acceptable parameters (4.3-12.0) while in hospital.
-Temperature will remain below 100.0F while in hospital
-Client will be free of symptoms of infection (fever, redness, pus discharge, and swelling) while in hospital
-Client will demonstrate appropriate care of infection prone site 3 days before discharge by washing hands, and performing appropriate wound care technique.
Interventions
-Wash hands before and after each patient care activity; ensure aseptic handling of all IV lines, ensure appropriate wound care technique
-Ensure appropriate hygienic care with hand washing; bathing, hair and nail, and perineal care performed by nurse or client
-Observe and report signs of infection I.e. redness, swelling, discharge, elevated temperatures.
-Teach client symptoms of infection that should be promptly reported to primary medical provider
Evaluation
-WBC levels consistently within parameter (4.3-12.0): 4.70, 5.60, and 5.40
-Oral temperature measured: 98.6F, 98.0F, no swelling, no discharge, redness present with complaints of pain.
-Client able to explain signs of infection by stating "if finds swelling, discharge, develops fever, excess redness he will report to care provider."
-Hand washing performed before/after all patient care/interaction; aseptic technique performed with IV line/picc; wound care instructions followed.
-Client reports fatigue.
Nursing DX
Chronic pain R/T Spinal Osteomyelitis AEB patient stating "his pain is 10/10 on a 1 to 10 scale."
Outcomes
-Client will use pain rating scale to identify level of pain intensity to determine comfort/function goal while in hospital
-Client will verbalize to staff when pain level reaches 5 on a 1 to 10 scale while in hospital
-Client's pain level will not exceed 8 on a 1 to 10 scale while in hospital
-Client's pain will be less than 2 within the hour after administration of pain medicine
Interventions
-Instruct client to notify staff when pain level reaches 5
-Medicate client as soon as reports pain 5/10
-Assess therapeutic effect of medication within 15minutes of administration
-Monitor client for any nausea/vomiting side effects
Evaluation
-Client reported pain reached 10/10 on a 1/10 scale
-Pain medication successful in reducing pain level to 2/10
-Client did not have any complaints of nausea/vomiting
What is the average flow rate for someone recieving 2 units of packed red blood cells for anemia? Also, what type of solution is packed red blood cells? Is it considered a hyptonic, isotonic or hypertonic solution? When a person is a anemic and needs to recieve blood are they at risk for a fluid vloume imbalance? My instructor said my main diagnosis should be Risk for deficient fluid volume and I dont understand why that would be the priority diagnosis. I am not sure what I would do for interventions ??? Any help would be much appreciated thanks...
Hi, I am an LPN nursing student and I need help with my care plan. I was put in hyperbaric oxygen therapy and I loved it. Anyway, I had a diabetic patient with a nonhealing wound on his left big toe. He comes to hyperbaric for treatment. His blood glucose was 275 before he went in. his bp was 130/70. his temp was normal 98.6. After treatment is blood glucose was 165 and bp was 150/70. That is all the information I got other than what was on his chart which was Impaired skin integrity. Please help!!!!
Specializes in med/surg, telemetry, IV therapy, mgmt.
what is the average flow rate for someone recieving 2 units of packed red blood cells for anemia? also, what type of solution is packed red blood cells? is it considered a hyptonic, isotonic or hypertonic solution? when a person is a anemic and needs to recieve blood are they at risk for a fluid vloume imbalance? my instructor said my main diagnosis should be risk for deficient fluid volume and i dont understand why that would be the priority diagnosis. i am not sure what i would do for interventions ??? any help would be much appreciated thanks...
what is the average flow rate for someone recieving 2 units of packed red blood cells for anemia?
average is about one unit per 2 hours. the drop factor of blood tubing is usually 20 gtts/ml and a unit of packed cells contains 250 mls. you do the math.
what type of solution is packed red blood cells?
it is the rbcs, wbcs, platelets and 20% of the plasma from one unit of whole blood. all other components have been removed by the blood bank. see
is it considered a hyptonic, isotonic or hypertonic solution?
isotonic.
when a person is a anemic and needs to receive blood are they at risk for a fluid volume imbalance?
yes.
risk for fluid volume imbalance
is a risk for an increase (overhydration)
or
decrease (dehydration) in fluids. patients are often at a fluid deficit if there has been hemorrhage. if too much saline is infused too rapidly with whole blood products the patient can become overhydrated.
my instructor said my main diagnosis should be risk for deficient fluid volume and i don't understand why that would be the priority diagnosis.
i don't know either because you have provided no other information about this patient.
deficient fluid volume
is dehydration, so she must feel that this patient is at risk for becoming dehydrated for some reason. i don't know anything about this patient so i don't know why that would be.
i am not sure what i would do for interventions.
interventions for "risk for" diagnoses are limited to:
strategies to prevent the problem from happening in the first place
monitoring for the specific signs and symptoms of this problem
reporting any symptoms that do occur to the doctor or other concerned professional
Specializes in med/surg, telemetry, IV therapy, mgmt.
Hi, I am an LPN nursing student and I need help with my care plan. I was put in hyperbaric oxygen therapy and I loved it. Anyway, I had a diabetic patient with a nonhealing wound on his left big toe. He comes to hyperbaric for treatment. His blood glucose was 275 before he went in. his bp was 130/70. his temp was normal 98.6. After treatment is blood glucose was 165 and bp was 150/70. That is all the information I got other than what was on his chart which was Impaired skin integrity. Please help!!!!
My instructor said my nursing care plans lack depth. Any tips? I try to pick interventions that make sense and write rationales, but my care plans are always short.
Specializes in med/surg, telemetry, IV therapy, mgmt.
My instructor said my nursing care plans lack depth. Any tips? I try to pick interventions that make sense and write rationales, but my care plans are always short.
Butterfly3001
255 Posts
daytonite:
i recived my npr back because my instructor said one of my client goals isn't appropriate. i wrote " the client will void at least 120ml by 11am on 11-03-08. she said that he has a foley so that i can't write void and that i should concentrate more on managment of the foley. so with that being said i looked in my npr and i am leaning toward writing. i don't even no where to begin. i don't want you to answer for me just some kind of guidance please on what i should focus on as far as the foley goes. thank you