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 everyone, i need help with a care plan that i have been pulling my hair out on. My nursing diagnosis is Impaired physical mobility r/t to gunshot to abdomen AEB surgical incision to abd.
Yes, I do. And I've looked at them - even though she (my professor) said NEVER to use them for maternity. She said this over and over during this term. I'm still not clear how to write the plan for the family?? We've gone over nothing in class about this, no suggestions except DON'T EVER USE A NURSING CARE PLAN BOOK from the prof. I was thinking about something like 'readiness for enhanced coping' rt new parent or something, but can find no description online or in any of the books that I am not supposed to use as to what this would look like, as they are ready for the baby, just new. Does that make sense?
Specializes in med/surg, telemetry, IV therapy, mgmt.
Hi,
Yes, I do. And I've looked at them - even though she (my professor) said NEVER to use them for maternity. She said this over and over during this term. I'm still not clear how to write the plan for the family?? We've gone over nothing in class about this, no suggestions except DON'T EVER USE A NURSING CARE PLAN BOOK from the prof. I was thinking about something like 'readiness for enhanced coping' rt new parent or something, but can find no description online or in any of the books that I am not supposed to use as to what this would look like, as they are ready for the baby, just new. Does that make sense?
A nursing diagnosis reference is not the same as a nursing care plan book. It is a book that contains all the nursing diagnoses, their definitions, defining characteristics and related factors. Diagnosing requires that an assessment of a situation be done first to determine what is going on and what problems are going on. You cannot write a plan of care until you identify some kind of problem. Readiness for Enhanced Coping sounds like a possibility if that is what your data suggests is going on. But if you looked in a nursing diagnosis reference like I suggested you would also havd foundd these diagnoses: Readiness for Enhanced Parenting and Readiness for Enhanced Family Processes so you are either not understanding what a nursing diagnosis reference is or you didn't do what I asked you to do. Nursing care plan books are going to give you diagnoses for medical conditions as well as nursing interventions and rationales for them which is why your instructor doesn't want you using them. She wants you to use the nursing process yourself to crank out this care plan step-by-step, which by the way is how the writers of those care plan books develop those care plans that are in them so they've already done the critical thinking for you.
Nursing Diagnosis Reference: NANDA International Nursing Diagnoses: Definitions and Classifications 2009-2011. This is not a book of care plans, but a listing of the 206 nursing diagnoses, their definitions, defining characteristics, related factors and what catagories they are classified into by NANDA.
Specializes in med/surg, telemetry, IV therapy, mgmt.
hi everyone, i need help with a care plan that i have been pulling my hair out on. my nursing diagnosis is impaired physical mobility r/t to gunshot to abdomen aeb surgical incision to abd.
first of all, your related factor is inappropriate. a gunshot to the abdomen is not an appropriate etiology (cause) of someone having limitation in independent, purposeful physical movement of the body or of one or more extremities (page 124, nanda international nursing diagnoses: definitions and classifications 2009-2011). there was either impairment of the muscles that are responsible for the movement, their ability to feel what they are doing with their limbs or pain. also your aeb (as evidenced by) part of the diagnostic statement is supposed to be the proof, or symptoms, you have that are the evidence of the impaired physical mobility. a surgical incision to the abdomen is not evidence of limitation in independent, purposeful physical movement of the body or of one or more extremities. your evidence would be things like the inability to move an arm or leg without assistance, difficulty turning in the bed, jerky movements, slowed and cautious movement or can't walk. so, you need to rethink what this nursing problem is and make sure you have diagnosed correctly and rewrite your diagnostic statement.
secondly, what help is it that you need with the care plan? you didn't say. did you read the early posts of this thread?
Specializes in med/surg, telemetry, IV therapy, mgmt.
i need help in writing this care plan,
the writing of a care plan follows the steps of the nursing process. the first thing you need to do is to collect together (make a list) all your assessment data of the patient. nursing assessment includes:
a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
the next thing you do is make a second list from that which includes everything that is abnormal. it is the abnormal data that is the evidence of the patient's nursing problems which you will probably know better as nursing diagnoses. once you know what the nursing problems are you can then develop nursing interventions to treat them. and, that is a care plan.
Man, you guys are amazing! This site gets better and better every day. I am so glad I found it!!
Here is my own deal...
I am in my first semester. We are behind because of insane snow storms, but we are rushing to catch up. We went over care plans in class, but of course, doing it at home, by yourself changes the game. The book I have doesn't follow how my prof wants it. I mean, the end result will be the same, but getting there is a whole diff map. I might just be confusing myself though. Anyway, any guidance would be great.
my lady is 84, taken care of at home by daughter. Admitted with dehydration and urosepsis, -dark yellow, oderous urine. Stage II ulcer on sacral-2cm diam 1cm depth, no drainage, tender surrounding, oriented x2, pale dry skin, poor skin turgor, dry mucous membranes, 140/98, HR=106, resp 20,98.8, weight 102-usually 115, thin extremities, minimal right leg movement, unequal palmmar grips-right weaker, red 2 cm spot on right elbow, minimal appiteite, refusing liquids, occassionally confused and disoriented in the past few months, incontinant of bowel and urine in the past few weeks. confined to bed.
So, she wants 2 nursing Dx--I selected:
1. Nutritional imbalance of less than the body requires related to the refusal of fluids and minimal appitite as reported by daughter,manifested by dark orderous urine, dry skin and poor skin turgor.
Planning: STG=Mrs Blank will consume adequate nutrition and increase fluid intake.
Observe clients ability to eat and relationship with food. Refusing to eat may be the only way Mrs Blankcan express control and it may be a symptom of depression.
Coordinate plan of care with health care provider, psychologist, Mrs Blank, and registered dietitian. Successful nutrition careplanning is amultidisciplinary approach throughout the continuum of care.
Encourage fluid intake. Older adults need eight 8oz glasses per day of fluid from beverage and food intake. Concentrating intake in morning and early afternoon is acceptable to prevent nocturia.
I am pretty sure we should have 4 of these. I thought I saw something about making meals social. And would like to add that, or maybe personalizing menu based off of results of observation. Maybe she needs soft foods, or more frequent smaller portions?
Then there is the matter of evaluations. I am supposed to just put what I want to happen? Such as "Skin is less dry, Turgor has improved." And Evaluation of goals is "Mrs Blank has improved physical parameters of nutrition"?
I feel like I am all over the place trying to piece this stuff together.
My second nursing Dx, is " Management of innefective family care related to care of skin integrity manifested by stage II pressure ulcer called a blister by care taker daughter."
I feel like maybe I am skipping my main focus. Maybe it should be the urosepsis, but I know my nursing dx should not include medical Dx,.....but maybe it should be somehwere? I am just lost. Any help wouldbe amazing. Thanks folks!
I am new to this site, but I am needing some help with care plans. I have seen a lot of examples and I have done care plans before, I'm just struggling with this one. I am trying to use a "readiness" diagnosis. I wrote my diagnosis as: "Readiness for enhanced coping r/t past divorce AEB verbalizing the desire to start counseling." I don't know if it is written correctly and I am needing help with desired outcomes! Thank you!!!!
Hi i am currently in my first semester in an accelerated nursing program, and i am writing a careplan on a patient with morbid obesity, chronic lower extremety lymphedema, CHF, PVD, Lung canver and many others. it has been emphasised over and over in class and at clinical that ABC's should be the priority on all patients. i was wondering if a nursing diagnosis with first priority: Impaired gas exchange will be a good one? and do i need to follow the ABC rule strictly when writing a care plan?
amops
2 Posts
Hi everyone, i need help with a care plan that i have been pulling my hair out on. My nursing diagnosis is Impaired physical mobility r/t to gunshot to abdomen AEB surgical incision to abd.