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.
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.
i think this is how i'll rank them:
1. impaired gas exchange r/t ventilation perfusion imbalance
2. decreased cardiac output
3. ineffective tissue perfusion: peripheral r/t interruption of vascular flow
4. excess fluid volume
5. disturbed sensory perception: vision
6. imbalanced nutrition: more than body requiremtents
Specializes in med/surg, telemetry, IV therapy, mgmt.
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.
this is how i would sequence them and why:
impaired gas exchange r/t ventilation perfusion imbalance (pneumonia and sputum production) [physiological need for oxygen - lungs]
decreased cardiac output (arrhythmia) [physiological need for oxygen - heart]
ineffective tissue perfusion: peripheral r/t interruption of vascular flow (pvd) [physiological need for oxygen - other body tissues]
excess fluid volume (edema) [physiological need for fluid]
imbalanced nutrition: more than body requirements (diabetes/insulin deficiency) [physiological need for food and nutrients]
pain r/t surgical incision (amputation) [physiological need for comfort]
risk of infection r/t surgical incision [anticipated safety need]
sputum production is not a symptom of impaired gas exchange; there's another diagnosis you need to use for that. the decreased cardiac output is also responsible for her hypertension. you've got the wrong imbalanced nutrition diagnosis to use with diabetes and insulin deficiency. does your diagnosis list distinguish between acute and chronic pain? she she have pain with her peripheral neuropathy? any other symptoms of disturbed sensory perception related to her peripheral neuropathy such as numbness in her hands and fingers? no impaired physical mobility having had double below the knee amputations? no self-care deficits are identified; hard to believe that she doesn't need help with some things.
risk of infection r/t surgical incision [anticipated safety need]
sputum production is not a symptom of impaired gas exchange; there's another diagnosis you need to use for that. the decreased cardiac output is also responsible for her hypertension. you've got the wrong imbalanced nutrition diagnosis to use with diabetes and insulin deficiency. does your diagnosis list distinguish between acute and chronic pain? she she have pain with her peripheral neuropathy? any other symptoms of disturbed sensory perception related to her peripheral neuropathy such as numbness in her hands and fingers? no impaired physical mobility having had double below the knee amputations? no self-care deficits are identified; hard to believe that she doesn't need help with some things.
i don't really have to do that many plans, so i stopped at 8, but yes, impaired physical mobility, self-care deficit both very much apply. i do need to specify acute/chronic pain. i don't believer she is being bothered by the neuropathy at this point as much as acute pain from the amputation and a sore shoulder.
as far as the impaired gas exchange, my ncp book says "...conditions that cause changes or collapse of the alveoli (e.g. atelectasis, pneumonia, pulmonary edema,...) impair ventilation. i think i see. she will have impaired gas exchange r/t pneumonia and decreased cardiac output. i'm tempted to use the sputum production in an ineffective airway clearance dx, but isn't it correct that if she is coughing up sputum, then it is actually effective clearance?
Specializes in med/surg, telemetry, IV therapy, mgmt.
i don't really have to do that many plans, so i stopped at 8, but yes, impaired physical mobility, self-care deficit both very much apply. i do need to specify acute/chronic pain. i don't believer she is being bothered by the neuropathy at this point as much as acute pain from the amputation and a sore shoulder.
as far as the impaired gas exchange, my ncp book says "...conditions that cause changes or collapse of the alveoli (e.g. atelectasis, pneumonia, pulmonary edema,...) impair ventilation. i think i see. she will have impaired gas exchange r/t pneumonia and decreased cardiac output. i'm tempted to use the sputum production in an ineffective airway clearance dx, but isn't it correct that if she is coughing up sputum, then it is actually effective clearance?
you can't say impaired gas exchange r/t pneumonia and decreased cardiac output. you cannot use a medical diagnoses (pneumonia) or another nursing diagnoses (decreased cardiac output) as the related factor on a physiologic nursing diagnosis. if you need to relate a nursing diagnosis (decreased cardiac output) to the nursing problem then just diagnose that as a nursing problem which you have already done. the cause of impaired gas exchange is that the oxygen and carbon dioxide are unable to move across the membrane separating the alveoli and the capillaries which is where these two gasses are swapped in our bodies. decreased cardiac output has nothing to do with that process. the part pneumonia plays in it is that the pus (an end product of the inflammation) that collects in the alveoli interferes (gets in the way) with the gas exchange process. that's why the taxonomy calls it "ventilation perfusion imbalance". oxygen and carbon dioxide are getting to the lungs (oxygen via inspiration; carbon dioxide via the capillaries of the pulmonary circulation), but because of all the congestion as a result of the pneumonia the exchange can't be made.
coughing up sputum is ineffective airway clearance r/t exudate in bronchi secondary to pneumonia aeb productive cough (it would be nice if you describe the sputum and the amount the patient is producing). does she have clear breath sounds? adventitious breath sounds are evidence of this as well and would be expected with pneumonia and a productive cough.
Help! I can't come up with a 3rd nursing diagnosis for my patient. She is a 57 yr. old pt with a hx of stage 3 renal failure, IDDM, HTN, hyperlipidemia, and neuropathy. She was admitted for observation due to hyperglycemia and elevated BUN and creatinine. She was discharged home the day I had her. She was placed on a 1800 cc fluid restriction. She's not on dialysis, she has a AV fistula, and an insulin pump. She's active, no breathing complications, no pain, voiding fine, and seems to be very educated and compliant with her health care management. So, far I have Risk for fluid volume excess and risk for injury. Please help.
Specializes in med/surg, telemetry, IV therapy, mgmt.
Help! I can't come up with a 3rd nursing diagnosis for my patient. She is a 57 yr. old pt with a hx of stage 3 renal failure, IDDM, HTN, hyperlipidemia, and neuropathy. She was admitted for observation due to hyperglycemia and elevated BUN and creatinine. She was discharged home the day I had her. She was placed on a 1800 cc fluid restriction. She's not on dialysis, she has a AV fistula, and an insulin pump. She's active, no breathing complications, no pain, voiding fine, and seems to be very educated and compliant with her health care management. So, far I have Risk for fluid volume excess and risk for injury. Please help.
Since she was admitted for observation because of the elevated BUN and creatinine why not do Deficient Knowledge, renal failure? Or, Deficient Knowledge, complications of renal disease?
can some one help with care plan i seem to never satisfy my instructor. my pt is 89 she is diagnosed with orthostatic dizziness, hypotension, her past medical hx consists of iddm, peripheral neuropathy, dementia, mi, chf, ashd, gerd, cad, cardiomyopathy,syncope, bladder suspension,urinary retention, urinary incontinence, uti, hysterectomy,sinus surgeryu,left lumpectomy, chronic atrial fib, anemia, meds she is on is alomide, coumadin, prilosec, tyelenol tab, vit b12 miralax coreg, novolog, lantus chest xray showed enlarged heart without congestion,gluc.143,bun 21, creat 0.8,gfr >60, na 143, k 4.3,cl 111,co2 26,hco3 25 agap 16, sed rate 46, troponin 20tsh 4.070, rbc 3.87, pt had decreased breath sounds, dizzy, nauseated, headache , pedal pulses were a +2, confused
Specializes in med/surg, telemetry, IV therapy, mgmt.
can some one help with care plan i seem to never satisfy my instructor. my pt is 89 she is diagnosed with orthostatic dizziness, hypotension, her past medical hx consists of iddm, peripheral neuropathy, dementia, mi, chf, ashd, gerd, cad, cardiomyopathy,syncope, bladder suspension,urinary retention, urinary incontinence, uti, hysterectomy,sinus surgeryu,left lumpectomy, chronic atrial fib, anemia, meds she is on is alomide, coumadin, prilosec, tyelenol tab, vit b12 miralax coreg, novolog, lantus chest xray showed enlarged heart without congestion,gluc.143,bun 21, creat 0.8,gfr >60, na 143, k 4.3,cl 111,co2 26,hco3 25 agap 16, sed rate 46, troponin 20tsh 4.070, rbc 3.87, pt had decreased breath sounds, dizzy, nauseated, headache , pedal pulses were a +2, confused
can some one help me with this?
thanks mary
hi, mary!
did you read some of the other posts on this thread? the first thing you need to do is break your data down and classify it. . .step 1 assessment - assessment consists of:
a health history (review of systems) - this is an 89 year old female who was diagnosed with orthostatic dizziness and hypotension. past medical history of iddm, peripheral neuropathy, dementia, mi, chf, ashd, gerd, cad, cardiomyopathy, syncope, urinary retention, urinary incontinence, a uti, chronic atrial fibrillation, and anemia. surgeries done consist of a bladder suspension, hysterectomy, sinus surgery, and a left lumpectomy.
performing a physical exam - assessment included decreased breath sounds, dizziness, nausea, headache, pedal pulses of +2, and confusion. abnormal labwork showed a glucose of 143 (unknown if this is fasting or postprandial), bun 21 (normal is 10 to 20), serum chloride 111 (normal is 90-110 meq in elderly adults), sedimentation rate 46 (normal is 20 or less/hour for a female), vitamin b-12 926 (normal adult 200-900), and rbcs 3.87 (normal elderly female 4.2-5.4). where is her pt level since she is on coumadin?
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - no assessment of this patient's adls was included in the information you provided.
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - since i am assuming that this patient was probably admitted with the orthostatic dizziness and hypotension (did she fall, by the way? and, what was, and is, her current blood pressure?) then these conditions need to be assessed for and looked up:
now, the reason i posted these websites is because you are missing a lot of information (signs and symptoms) that you need for this care plan. from the labwork, the medications and the long list of medical history that was posted i expected to see this patient having a lot of abnormal assessment items, particularly self-care deficits. there was nothing. by reading about these different conditions, look at the signs and symptoms and see if you missed seeing any of them in this patient and add them to a list now. you need that information in order to come up with this patient's diagnoses. all nursing diagnoses must have evidence (signs and symptoms to support them.
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - medications she is on are alomide (this is given for ocular hypertension--does she have glaucoma or are they trying to prevent it? does she have vision problems?), coumadin (anticoagulant), prilosec (for the gerd), tylenol tab (for pain--is this for her headache?), vit b12 (for her b-12 deficiency), miralax (laxative--does she have a constipation problem?), coreg (antihypertensive--does she have high blood pressure--no vital signs were posted), novolog (for diabetes), and lantus (for diabetes). a chest xray showed an enlarged heart without congestion (is this patient obese?).
step #2 determination of the patient's problem(s)/nursing diagnosis - make a list of the patients abnormal assessment data. this data becomes the evidence that will support the nursing diagnoses you will choose. every nursing diagnosis has a list of defining characteristics (signs and symptoms). the only information you listed (and i am sure there is more you just haven't thought to include) is
decreased breath sounds
dizziness
nausea
headache
pedal pulses of +2
confusion - this really needs to be more specific
glucose of 143 (unknown if this is fasting or postprandial)
bun 21 (normal is 10 to 20)
serum chloride 111 (normal is 90-110 meq in elderly adults)
sedimentation rate 46 (normal is 20 or less/hour for a female) - this is a general indication of an infection somewhere in her body, best guess is that it is the respiratory or urinary track in the elderly
vitamin b-12 926 (normal adult 200-900)
rbcs 3.87 (normal elderly female 4.2-5.4)
from these, possible nursing diagnoses are. . .
decreased cardiac output
ineffective tissue perfusion, peripheral
imbalanced nutrition: less than body requirements
nausea
total urinary incontinence
acute pain
chronic confusion
ineffective protection
risk for infection
risk for impaired skin breakdown
???? mobility, visual problems, self-care deficits, constipation (is she incontinent of bowel?)
I chose the topic of Sudden Infant Death Syndrome for a term paper for school and have found lots of journal articles, but have to submit 2 complete nursing diagnosis and could not think of 2 medical dx. Grieving r/t loss could be one, but can anyone think of a good medical diagnosis.
Risk for Impaired Oxygenation r/t SIDS doesn't sound right. SIDS is such a horrible disease and truly so sudden and permanent, it doesn't seem like there are any good choices for diagnosis.
Specializes in med/surg, telemetry, IV therapy, mgmt.
hi all,
i chose the topic of sudden infant death syndrome for a term paper for school and have found lots of journal articles, but have to submit 2 complete nursing diagnosis and could not think of 2 medical dx. grieving r/t loss could be one, but can anyone think of a good medical diagnosis.
risk for impaired oxygenation r/t sids doesn't sound right. sids is such a horrible disease and truly so sudden and permanent, it doesn't seem like there are any good choices for diagnosis.
thanks so much for all of your help!
i saw your problem already when you posted "but can anyone think of a good medical diagnosis". a nursing care plan consists of nursing diagnoses which are nursing problems based upon the symptoms that the patient will have. those are determined by making an assessment of the patient. if you read the many replies i have made to this thread you will find what is meant by assessment. sudden infant death syndrome is a medical diagnosis and it can be broken down into signs and symptoms which you can then use to determine the nursing problems of the patient. nursing diagnoses are not the same as medical diagnoses.
since i assume you are writing about the patient, grieving r/t loss would not be an appropriate nursing diagnosis for the baby. risk for impaired oxygenation r/t sids would also be wrong because there is no nanda diagnosis called risk for impaired oxygenation and you cannot use a medical diagnosis (sids) as a related factor in a nursing diagnostic statement.
one potential nursing problem would be disturbed sleep pattern r/t apnea monitoring aeb [symptoms of disturbed sleep in the patient]. another would be caregiver role strain r/t 24 hour care requirements of patient aeb [symptoms of difficulty in care being given to patient].
you need to look up the pathophysiology and the signs and symptoms of sids:
can some one help with
daveintexas8
34 Posts
i think this is how i'll rank them:
1. impaired gas exchange r/t ventilation perfusion imbalance
2. decreased cardiac output
3. ineffective tissue perfusion: peripheral r/t interruption of vascular flow
4. excess fluid volume
5. disturbed sensory perception: vision
6. imbalanced nutrition: more than body requiremtents
7. pain r/t surgical incision
8. risk of infection r/t surgical incision