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.
Specializes in med/surg, telemetry, IV therapy, mgmt.
i know what you mean about they shouldn't be overjoyed about the spiritual thing, but for some reason our instructors want their 'happiness' to be up there on the list of priorities because if they are stressed or unhappy then the body may 'resist' healing or something to that effect. i, personally think acute pain trumps all else, but they are "tired" of seeing that as a nd. i guess more than anything, i'm having trouble reading minds :chuckle
i will put your list and advise to good use though, thank you so much.
side note- i don't know if you get paid to do what you do, but i think allnurses.com should hold a bake sale or something to raise money to give to you as a thank you for how much you do on this site and how many people you help....until then, my gratitude is what i can offer!...so thank you!
if you are required to include psychosocial diagnoses then sequence them appropriately. physiological needs come first and psychosocial needs last. people die of lack or air and food first before missing church services. so sequence respiratory and nutrition diagnoses before spiritual ones. see maslow: http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs. pain is a comfort issue. i don't think it is a priority either although some instructors do. with maslow, it is a physiological need, but at the low end of the physiological needs. impaired skin with surgical patients is another controversial one. some see it as a safety need for protection and others see a break in the skin as a physiological need. the cause (etiology) of the problem may also determine where the diagnose lands in the list of the sequencing.
Impaired gas exchange r/t post-anesthesia and immobility
2
Disturbed body image r/t colostomy
3
Excess fluid volume r/t infusion of fluids following surgery
4
Acute confusion r/t dementia
5
Self-care deficit r/t decreased mobility
6
Spiritual distress r/t separation from spiritual and cultural ties.
7
Risk for infection r/t surgical incision
8
Risk for impaired skin integrity r/t decreased activity, medical restrictions and prolonged bedrest
I don't know if this is enough to go on, but is this more on the right track? I put the "risk for" last since it is not an actual dx
I am truly at a loss and I feel like sometimes I have to reallly stretch to come up with some of these. Is that common with nursing students? or am I just not seeing what I need to see?
Specializes in med/surg, telemetry, IV therapy, mgmt.
here are my 8 nd's that i came up with
1
impaired gas exchange r/t post-anesthesia and immobility
2
disturbed body image r/t colostomy
3
excess fluid volume r/t infusion of fluids following surgery
4
acute confusion r/t dementia
5
self-care deficit r/t decreased mobility
6
spiritual distress r/t separation from spiritual and cultural ties.
7
risk for infection r/t surgical incision
8
risk for impaired skin integrity r/t decreased activity, medical restrictions and prolonged bedrest
i don't know if this is enough to go on, but is this more on the right track? i put the "risk for" last since it is not an actual dx
i am truly at a loss and i feel like sometimes i have to reallly stretch to come up with some of these. is that common with nursing students? or am i just not seeing what i need to see?
this is the correct sequencing by priority for these nursing diagnoses and problems with the related factors:
impaired gas exchange r/t post-anesthesia and immobility
please look at the nanda taxonomy that contains the definition and related factors for this diagnosis. it tells you that impaired gas exchange is defined as excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane (pg. 112, nanda international nursing diagnoses: definitions and classifications 2009-2011). if you have a copy of taber's cyclopedic medical dictionary this information is in the appendix. post-anesthesia and immobility is not the physiologic cause of this patient's excess or deficit in oxygenation and/or carbon dioxide elimination in the alveoli of their lungs. anesthesia is a medical treatment and you cannot use it as an explanation for one of the body's physiological problems. ditto with immobility which is a patient problem. there are two main reasons why the alveoli of the lungs fail to do their job in exchanging these two gasses: (1) they are damaged (alveolar-capillary membrane changes) or, (2) they are so gunked up that the gasses have no room to get into the air sacs for air exchange to occur resulting in exchange imbalances (ventilation perfusion imbalance). in a surgical patient without any chronic lung disease, the related factor is ventilation perfusion imbalance.
[*]excess fluid volume r/t infusion of fluids following surgery
somehow i really doubt this is realistic. you are saying that the doctor is making an error. nurses are monitoring the patient, as is the doctor. labs are being drawn daily. overhydration would be seen in the lab data. the sodium levels would be elevated along with other labwork.
[*]self-care deficit r/t decreased mobility
you must specify the self-care deficit. there are 4 of them.
decreased mobility is a entire other nursing problem.
if the patient is unable to perform adls because of a difficulty to move, the correct way to state that is either weakness, musculoskelatal impairment or neuromuscular impairment
[*]acute confusion r/t dementia
[*]disturbed body image r/t colostomy
i would be more specific about what the patient fears about the colostomy doing to disturb her self-picture than the colostomy itself. this is a psychosocial (behavioral) diagnosis, so her thinking should be incorporated in the related factor. is it something along the line of fear of rejection or is it the thought of disfigurement?
[*]spiritual distress r/t separation from spiritual and cultural ties
cultural ties do not make sense for why a person is spiritually distressed.
you should include acute illness as a related cause.
[*]risk for infection r/t surgical incision
[*]risk for impaired skin integrity r/t decreased activity, medical restrictions and prolonged bedrest
the risk factor is what will result in the skin breaking down. you need to specify the medical restrictions.
this diagnosis is redundant because this patient already has impaired tissue integrity as a result of surgery which you failed to diagnose.
i am truly at a loss and i feel like sometimes i have to reallly stretch to come up with some of these. is that common with nursing students? or am i just not seeing what i need to see?
you become more proficient at diagnosing as you work with the diagnosing and do more of it. use the nursing process. assess. use a nursing diagnosis reference. practice. diagnosing is a mental skill.
Hi everyone I'm at the end of my first yr. of nursing school, I'm doing my clinical right now and I'm trying to do a care plan on Anemia I'm using Activity intolerance but I can't seem to come up with any patient centered goals. She has fatigue, dizziness, weakness. Any help would be greatly appreciated...
Specializes in med/surg, telemetry, IV therapy, mgmt.
hi everyone i'm at the end of my first yr. of nursing school, i'm doing my clinical right now and i'm trying to do a care plan on anemia i'm using activity intolerance but i can't seem to come up with any patient centered goals. she has fatigue, dizziness, weakness. any help would be greatly appreciated...
goals are not developed until the nursing diagnoses are determined. the goals are based upon the related factors and the supporting evidence. so, if i am getting your information correct, this patient has the following nursing problem:
activity intolerance r/t ____ secondary to anemia aeb fatigue, dizziness and weakness.
do you have a pathophysiology for this activity intolerance? were you thinking that it was an imbalance between oxygen supply and demand? is this blood loss anemia or an iron deficiency anemia? this diagnosis is one that involves symptoms of the respiratory and cardiac systems and when the patient begins to move their heart and respiratory rates elevate causing them to become sob. that results in the fatigue and weakness so that the patient ends up having to stop the activity. its unfortunate you don't have some vital signs as well to add to your evidence here.
Hi this is my first time posting! Here is my scenario: My pt is a 58 y/o female with multiple & I mean MULTIPLE diagnosis. I have to do a nursing diagnosis on nutrition. She is obese, approximately 32 lbs above her IBW. She had a gastric bypass surgery in Sept 2008 and since has lost 20 lbs (she is still 30 lbs overweight). All her labs regarding nutrition are WNL, albumin, pre-albumin, etc. So should my diagnosis be related to her obesity or her gastric bypass? Should it be:Imbalanced nutrition, less than body requirements r/t early satiety resulting from small gastric pouch and delayed pouch empyting, or Imbalanced nutrition, more than body requirements r/t poor dietary habits (or inadequate excercise because she said she gained a lot of weight after having complications from her COPD since she couldn't be as active). Which diagnosis is appropriate? I would appreciate any help I can get. I am sure this is very simple & I just can't figure it out due to lack of sleep! Thanks in advance
Specializes in med/surg, telemetry, IV therapy, mgmt.
hi this is my first time posting! here is my scenario: my pt is a 58 y/o female with multiple & i mean multiple diagnosis. i have to do a nursing diagnosis on nutrition. she is obese, approximately 32 lbs above her ibw. she had a gastric bypass surgery in sept 2008 and since has lost 20 lbs (she is still 30 lbs overweight). all her labs regarding nutrition are wnl, albumin, pre-albumin, etc. so should my diagnosis be related to her obesity or her gastric bypass? should it be:imbalanced nutrition, less than body requirements r/t early satiety resulting from small gastric pouch and delayed pouch empyting, or imbalanced nutrition, more than body requirements r/t poor dietary habits (or inadequate excercise because she said she gained a lot of weight after having complications from her copd since she couldn't be as active). which diagnosis is appropriate? i would appreciate any help i can get. i am sure this is very simple & i just can't figure it out due to lack of sleep! thanks in advance
a diagnosis is based on your assessment information that you have collected. i am pretty sure that imbalanced nutrition, more than body requirements is an absolutely incorrect diagnosis. no one who has had gastric bypass surgery is physically capable of an intake of nutrients that exceeds metabolic needs, the definition of this diagnosis, unless they devote most of their waking hours to eating something (we call it grazing). the fact that she has been losing weight is evidence that she isn't doing that.
did you look up what the gastric bypass surgery is?
they deliberately restrict the size of the stomach which results in the restriction of food intake and the inability of the body to absorb nutrients.
imbalanced nutrition, less than body requirements r/t early satiety resulting from small gastric pouch and delayed pouch empyting
i had a silastic ring bypass several years ago. early satiety (being satisfied) is a wanted result of this surgery and is part of portion size control. unless this patient described how much food it took to reach satiety, she may be fooling you. this is why i am wondering what your supporting evidence is. i attend gastric support groups regularly and talk with people who are considering the surgery. they are shocked when they hear us talk about how much (actually, how little) we eat. it is because some people are at 300 and 400 pounds and eating 6000 calories a day. to them, a 1200 calorie diet is a between meal snack.
the reasoning behind the
imbalanced nutrition: less than body requirements
(definition:
intake of nutrients insufficient to meet metabolic needs
) is
restricted size of stomach and inability of the body to absorb nutrients
. the symptom of this would be the
20 pound weight loss
. does she have any hair loss? this happens to some bypass patients in the first 6-8 months. did you ask her about being hungry? one thing that is pretty common with bypass surgery is that many people do
not
get hungry. we ask that a lot at our support groups and a common answer is, "no, we don't get hungry anymore." we also lose the taste for sweets. in some people this may happen over time. i used to be a big candy eater and now i can walk by candy and cookies and not even crave or want them. there are vitamin deficiencies also. the lab tests are not always done for these because of the expense and the deficiencies don't show symptoms until they are well underway. i take vitamins, minerals and iron replacement daily. what vitamin replacements is this patient taking?
Thanks Daytonite! I really appreciate your help. I thought Imbalanced nutrition more than body requirements, didn't seem right but I just needed to be sure I was on the right track. Could I do a diagnosis for Risk for imbalanced nutrition less than body requirements? Because at the moment she reports: feeling of getting hungry, feeling of being satisfied after eating, no hair loss & her labs are WNL. She is taking Os-Cal as a calcium supplement, but is not taking any vitamins. So it doesn't appear that she has altered nutrition at the moment, but there is a definite risk for it due to gastric bypass & not taking vitamin supplements.
Specializes in med/surg, telemetry, IV therapy, mgmt.
Thanks Daytonite! I really appreciate your help. I thought Imbalanced nutrition more than body requirements, didn't seem right but I just needed to be sure I was on the right track. Could I do a diagnosis for Risk for imbalanced nutrition less than body requirements? Because at the moment she reports: feeling of getting hungry, feeling of being satisfied after eating, no hair loss & her labs are WNL. She is taking Os-Cal as a calcium supplement, but is not taking any vitamins. So it doesn't appear that she has altered nutrition at the moment, but there is a definite risk for it due to gastric bypass & not taking vitamin supplements.
Thanks so much! You are a lifesaver!
I would say no to that. The surgery was done so her anatomy has been altered and the etiology is there. If she is not taking her vitamins then she needs to. Why isn't she taking them? It sounds like she has not been following the recommended medical regime. I'd tag her with Ineffective Health Maintenance and get a lot of teaching in. In a few years she's going to be having malnutrition as a medical diagnosis.
I always have a problem writing appropriate nursing diagnosis. This is sad. What's more, nurses in Malaysia don't really practice this. It's only taught in degree students...
Specializes in med/surg, telemetry, IV therapy, mgmt.
I always have a problem writing appropriate nursing diagnosis. This is sad. What's more, nurses in Malaysia don't really practice this. It's only taught in degree students...
When I was first taught this I didn't understand it either. It is why I work so hard to answer nursing diagnosis questions from students. It is, by far, the most commonly asked type of question with regard to care planning. I try to break the process of diagnosing down. It is very similar to how doctors diagnose medical disease. The difference is that we assess the patients to collect different types of data and then apply this data to a different set of diagnostic problems (nursing diagnoses). Thankfully, our list of nursing diagnoses is much shorter in length than the list of medical diseases and conditions. That, however, doesn't make the process of diagnosing any less mysterious. In all the care planning books I have as references, none of them explains the act of diagnosing very well. I often wonder how medical students are taught this skill.
Hi there. I'm doing a Major Care Plan for this semester. I've got the pathos and care plans down, but was just wanting some guidance on prioritizing my Dx list.
My patient is an elderly female. She presented to the ED with pneumonia. Her past medical dxs include end-stage renal failure, DM, morbid obesity, diabetic nephropathy and neuropathy, a fib, PVD, HTN, etc. She's had double below the knee amputations (one years ago, the other a couple of weeks ago.) You get the idea.....
Anyway, I'm going to go with:
1. Impaired Gas Exchange R/T Ventilation Perfusion Imbalance (Pneumonia and sputum production)
2. Decreased Cardiac Output (Arrythmia)
3. Imbalanced Nutrition: More than Body Requiremtents (Diabetes/insulin deficiency)
Waddya think? I'm thinking ABCs with my ranking of 1 and 2, but I'm not sure about 3-6. I'm thinking I probably need to bump the tissue perfusion to #3. That's a circulation issue, but then there's the fluid volume! It's all important.
BTW, thanks to all of you that help us students. (esp. Daytonite, of course),
Dave
EDIT: I forgot to add that she is legally blind, so I'll add Disturbed Sensory Perception: Vision, too.
Daytonite, BSN, RN
1 Article; 14,604 Posts
if you are required to include psychosocial diagnoses then sequence them appropriately. physiological needs come first and psychosocial needs last. people die of lack or air and food first before missing church services. so sequence respiratory and nutrition diagnoses before spiritual ones. see maslow: http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs. pain is a comfort issue. i don't think it is a priority either although some instructors do. with maslow, it is a physiological need, but at the low end of the physiological needs. impaired skin with surgical patients is another controversial one. some see it as a safety need for protection and others see a break in the skin as a physiological need. the cause (etiology) of the problem may also determine where the diagnose lands in the list of the sequencing.