Help with Care Plans

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. Nursing Students General Students Knowledge

Updated:  

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)
  • Implementation (initiate the care plan)
  • Evaluation (determine if goals/outcomes have been met)

Why we should use care plans?

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

  1. 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.
  2. You determine that you have a flat tire. You have just done step #2 of the nursing process--made a diagnosis.
  3. 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).
  4. 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.
  5. 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).

  • Activity Intolerance: (page 3, nanda-I nursing diagnoses: definitions & classification 2007-2008)
  • 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 Acute Mental Health.

I'm getting a much better pic of the collaborative process. What I've figured out is that I've been calling it an collaborative DX, but it's just a colloborative problem that is put into the nursing DX column of the care plan. I'll find out for sure if I'm on the right track tomorrow. I'll let you know.

Specializes in CVICU, ER.

Thank you for all of this useful info. I am confused on the pica definition though. Not to argue, by no means can I possibly know more than an actual practicing nurse, but I thought that pica was a craving for anything that was of little nutritional value, food or non-food items. In fact, here is a little snippet from www.americanpregnancy.org

What are typical pica cravings during pregnancy?

The most common substances craved during pregnancy are dirt, clay, and laundry starch. Other pica cravings include: burnt matches, stones, charcoal, mothballs, ice, cornstarch, toothpaste, soap, sand, plaster, coffee grounds, baking soda, and cigarette ashes.]

They state that a craving for items such as this might indicate an iron deficiency. So, what I am wondering, would it be a medical diagnosis still if we said risk for low blood volume r/t pregnancy ?? The only post surgical problem this pt had was pain. I may use self care deficit, but my instructor is always asking "what will kill your patient first".... In this case, all I can think of is the blood loss, and infection..... Thanks

Specializes in med/surg, telemetry, IV therapy, mgmt.
rwright15 said:
I am wondering, would it be a medical diagnosis still if we said risk for low blood volume r/t pregnancy ?? The only post surgical problem this pt had was pain. I may use self care deficit, but my instructor is always asking "what will kill your patient first".... In this case, all I can think of is the blood loss, and infection..... Thanks

My advice is not to address pica. The actual problems this patient are going to have for sure are related to her incision and mobility. Then, she has potential problems related to possible complications (fluid loss due to blood loss, infection due to incision infection, thrombophlebitis if she is spending more time in bed than she should, UTI)

Specializes in CVICU, ER.

Thank you so much, that sounds great!! I think I will go with mobility.... Thank you again for the wisdom. You are truly an asset to this website...

Specializes in Acute Mental Health.

Thank you all for helping me sort out the Potential Complication part of my last 2 care plans. My instructor wrote that I had really good data and did a good overall job. I will continue to work on wording..... Others had to redo theirs, so I'm grateful that I found this site or I'd be burning the midnight oil so to speak instead of relaxing and spending time cruising this site .

Thanks again!

Specializes in Acute Care Psych, DNP Student.

My clinical instructor requires us to list 'as manifested by' for risk diagnoses. She said to ignore our textbooks that say 'risk for' is a two-part.

In fact, we had a major paper due recently (not part of weekly clinical care-plans) and she booted my paper right back to me to fix and make 'risk for' a three part diagnosis. I thought she was just doing this in our weekly carepans for clincal, but no. It's for major papers as well. Is this unusual?

Specializes in med/surg, telemetry, IV therapy, mgmt.
multicollinearity said:

My clinical instructor requires us to list 'as manifested by' for risk diagnoses. She said to ignore our textbooks that say 'risk for' is a two-part.

In fact, we had a major paper due recently (not part of weekly clinical care-plans) and she booted my paper right back to me to fix and make 'risk for' a three part diagnosis. I thought she was just doing this in our weekly care plans for clinical, but no. It's for major papers as well. Is this unusual?

It doesn't follow nanda guidelines. However, this is a school and grading situation and you are obliged to follow the rules you are given. This is really not a problem as long as the instructor applies the rules consistently in grading. I would make sure that your manifested evidence for these diagnoses clearly relates to a specific problem that you're addressing.

In my bsn program we were not allowed to use nanda wording (language) for our nursing diagnoses. We had to construct nursing diagnoses using language that conveyed the nursing problem but did not duplicate what nanda said. It was possible to do that using a copy of roget's thesaurus for reference.

2nd semester student here...I need some help...My patient last night was a 98 yr old female w/admitting diagnoses of Jaundice. She also had a small stage 2 pressure ulcer-sacral. Her past history included multiple falls, Hypertension, CHF, Renal Failure, Osteoporosis. Currently suffering from severe diarrhea, and also had an ERCP done on 4/17--"multiple stones, stent placed" The only medications listed was Flagyl, 250 mg at 16:00 and 22:00, Darvocet bid and ASA 81 mg / day

she was currently on 3 liters of O2 nasal cannula.

When I initially went to her room, I was told that she had been moved to a room closer to the nurses station as she was failing quickly. She was not responding other than opening her eyes once in awhile, when I spoke to her and was restless, but earlier in the day she I was told by the nurse that she was having pretty normal conversations with her.

Pulse was 93, respirations: 36 BP 102/82 pulse ox 73.

She was put on 15 liters O2 non rebreather mask.

she went further downhill... Resp. 42 & shallow, BP 60/36 pulse 90,and within 2 hours her care was changed to "comfort measures" --(had a DNR)--all meds d/c'd, morphine 1-2 mg q 2 hours, IV. They didn't think she would make It through the night.

I'm attempting to start a careplan to turn in to my instructor. (boy, its tough to not get emotional!) I admit to having problems prioritizing (as indicated by my last request for help!) but where do I start? Do I begin with the information I was given, and then progress to "Death anxiety?" I need 4 Nursing Diagnoses... I have several in mind, but this patient was dying. I think her pain and making her as comfortable as possible is most important, yet working up 3 assessments, 3 interventions and 3 teachings on FOUR diagnoses has me in a quandry.

I'm starting to work on this now, and will check back for some advice if someone can help. I really appreciate it!

:bugeyes:

Specializes in med/surg, telemetry, IV therapy, mgmt.

How to go about starting a care plan was detailed in the first few posts of this thread.

  1. Make a list of your patient's symptoms
    • jaundice
    • stage 2 pressure ulcer on the sacrum (what were the measurements, any drainage, appearance?)
    • history of multiple falls
    • severe diarrhea (how many a day?)
    • multiple stones and stent placed per ercp on 4/17 (where were these stones and were they the cause of the jaundice?)
    • flagyl, 250 mg (why was she getting flagyl? what kind of infection was being treated?)
    • darvocet bid (where was the pain that this was addressing?)
    • asa 81 mg / day
    • 15 liters o2 non rebreather mask (did you get any lung sounds or blood gas results?)
    • pulse was 93, respirations: 36, then went to resp. 42 & shallow, bp 60/36 pulse 90
    • pulse ox 73
    • not responding other than opening her eyes once in awhile
    • restless
    • her care was changed to "comfort measures" - dnr
    • all meds d/c'd, morphine 1-2 mg q 2 hours, iv
  2. Using that list you will determine your patient's 4 nursing problems (nursing diagnoses)
    • if you had more lung assessment information other diagnoses could be used - these are prioritized by maslow
      • impaired gas exchange (supporting evidence: pulse ox of 73, restlessness, pulse of 93)
      • ineffective breathing pattern (supporting evidence: respiratory rate of 42 and pulse of 93)
      • diarrhea (supporting evidence: severe diarrhea - needs more description)
      • impaired physical mobility (supporting evidence: not responding other than opening her eyes once in awhile, placed on morphine - you also need more description that she is not moving or turning on her own)
      • impaired skin integrity (supporting evidence: description of the stage ii sacral ulcer)
      • chronic pain (supporting evidence: ?, getting an analgesic)
      • risk for falls (supporting evidence: history of multiple falls)
  3. Determine goals - based upon the results you expect from the nursing interventions you will be ordering

  4. Determine nursing interventions - ordered for the supporting evidence (symptoms) associated with each nursing diagnosis

To use death anxiety the patient has to be making statements to you or the others on staff about concerns about her death, yet you have listed nothing about that.

To diagnose, you really need to use a nursing diagnosis reference since every nursing diagnosis has a set of defining characteristics (symptoms) and your patient must match with at least one of them. i used nanda-i nursing diagnoses: definitions & classification 2007-2008 to double-check the supporting evidence (defining characteristics) for the diagnoses i chose above.

In my opinion, the two top priority diagnoses that i would treat are where most of the nursing care would be focused: keeping the airway open and keeping the patient turned

  1. Ineffective breathing pattern
  2. Impaired physical mobility

The choice of what to use for priority diagnosis depends on the behavior the patient is exhibiting. You seem to indicate that she has pain, but my thinking is that her breathing is probably more of a problem which the morphine will help.

I really appreciate the time you've taken to reply to my request. I wish I could send you a box of chocolate!

I have a bit more information...Some of the information is missing, and even my instructor could not find it in the chart.

The pressure ulcer was about 3 cm in diameter, slight drainage...serosanguaneous Although the patient wasn't talking by the time I got there, she would grimace and moan slightly when positioned on her back, so we opted to move her from side to side..however, the nurse said she had alot of pain in her left hip, verbalized by the patient earlier in the day. Xray did not show any fracture. The darvocet was prescribed for the complaints of pain from lying on her back (?pressure ulcer?) and her

hip.

The only entry in the chart regarding he ERCP was that she had Obstructive Jaundice.

The "severe diarrhea"--that was my description. In thinking about it, it was watery stools, but 4 to 5 per day. We could not find an indication for the Flagyl.

her lung sounds were clear, but her very shallow breathing made it difficult to evaluate completely as she couldn't respond with deep breathing. Did I miss something here?

No ABG's were drawn - her respirations went down quickly, and the nurse got an order for the rebreather mask asap---before that she was on 3 liters / nasal cannula (Not sure if I mentioned that)

Her labs were: WBC 8.9 RBC 3.93 (L) Hgb 13.4, Hct 39.5, Platelet count 127 (L) Na 141, K 3.7 BUN 66 (H) CREATNINE 3.1 (H) GFR i 15 (less than 15 is kidney failure, right?) These were drawn that morning.

The staff nurse told me that when she was talking earlier in the day, she told her "I think I'm dying-I hope my family understands-I'm tired"

I have worked up impaired gas exchange and ineffective breathing pattern so far, and started on pain. I just don't know if I have enough based on her statement of death to consider it death anxiety--she was definitely anxious/restless, but I would be too if I couldn't get enough O2!

Just want to say that I think you are a saint. I've printed and spent some more time on this site, including the links you suggested. They too were helpful. Thanks again for your time.

Thank you so much for that very detailed description. I am going into my second year at a Community College and I am hoping with your help that I will be able to write authentic care plans using my own assessment findings:yeah:and not some book that a seasoned professional has written. We as students sometimes take the short cut if only we would take our time and actually get the understanding. We are so overwhelmed with work and listening to other nurses saying they don't have to do care plans, we just take a short cut instead of really understanding. It would also proably help with us during our testing. Thanks again

Can anyone help distinguish GOALS as opposed to EXPECTED OUTCOMES?

I am really struggling with my very first care plan - for a lady who has been admitted for asthma exacerbated by an URTI, and we have to focus on the nursing diagnosis of Impaired Gas Exachange.

I can detail a whole bunch of expected outcomes, because they are specific, measurable etc etc, but what then is a goal? Is it just a broader overview of all the EO's? Is it something to do with the 5 goals of respiratory care; clear the airway, mobilise secretions, reduce WOB, oxygenate system and promote compliance and self care...?

AHH!! I've been an AIN for ages now, who ever knew I'd struggle so much with this!