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.
you are always going to look at what was abnormal about your assessment of your patient because those are the clues (evidence) of their nursing problems. the coorifice breath sounds bilaterally, weak, ineffective cough, and patchy infiltrates in rml, rll, and lll are defining characteristics (symptoms) of ineffective airway clearance...
Thanks for helping out!! it cleared up some confusion I was having for sure, and also taught me a lot! ?
I am about to be a senior in the fall. This info would have been a life saver had I had it earlier! I used the oldfashioned, have no clue what the vague directions meant, discuss it with my fellow lost classmates, and guess, get a bad grade, and improve so much by the end of the semester that I pass. So glad I have found you now!
elow!! i am just new here and i am a second year nursing student... can you please help me how to make a good NCP?? it will be my first time to make one... please... tnx
Specializes in med/surg, telemetry, IV therapy, mgmt.
elow!! i am just new here and i am a second year nursing student... can you please help me how to make a good NCP?? it will be my first time to make one... please... tnx
Did you read Post #1 and #2 of this thread? After reading all that information, what else, specifically do you have a question about?
This thread is a big help...thanks. But honestly, I'm still a little confused and frustrated. I'm a 3rd year BSN student preparing for my first case presentation, the case is actually easy - PIH, but sad to say my team and I couldn't get the facts/info that we need to support our case. Ideally, we can't make an NCP based on assumptions...we need lab results, monitoring sheets and others, unfortunately we couldn't get those from the hospital we were assigned to (they don't even have complete lab tests, and other data essential to the patient's case). We were assigned in a Charity Ward of a Provincial Hospital and in a 3rd world country like ours - it isn't an ideal setting.
I just feel sad that we couldn't do what we think is proper and ideal; we couldn't apply what we learned in school because we have to follow 'hospital tradition' which includes habitual compromises on health procedures.
any suggestions would be greatly appreciated..our instructor is not very informative..we are basically teaching ourselves.
a teaching plan expands on nursing interventions that are of a teaching nature and whose audience are the patient or caregivers who need specific information on how the supervising nurse wants some specific procedure to be done for the patient or some specific information to be imparted to them. the teaching format you were given is correct. I can expand on and define those terms for you.
learning objectives - specific information that the learner will come away from the course knowing; goal(s) you have determined the learner will achieve.
specific content - the specific content that you are going to teach and in the sequence it will happen (an outline). your content should address and cover all the objectives. this part of the written lesson plan is often handed in to the instructor and handed out to your audience in an outline format
teaching strategies - a strategy is a plan of action and is how all the above will be achieved. lecture, demonstration, case study analysis, role playing, discussion, audio-visuals, handouts, experiments, stories, game playing and any number of other creative items.
type of learning - (how people learn) visual (seeing), aural (hearing), read/write (touch), kinesthetic (movement)
evaluation methodology - determining if you met the goals of the teaching plan. this can be done through a return demonstration, short posttest, short question and return answer session with the client to verify they understand the information correctly or a task the participant needs to perform.
you can see examples of teaching for consumers on consumer websites all over the internet. I just found one this morning: halifax health disease, condition & injury fact sheets
a care plan is not a teaching plan. a care plan is the written documentation of your thinking process in identifying the patient's nursing problems and your strategies to solve them. your solutions (strategies, nursing interventions) to these problems take the form of 4 different types/actions:
assess/monitor/evaluate/observe (to evaluate the patient's condition)
care/perform/provide/assist (performing actual patient care)
teach/educate/instruct/supervise (educating patient or caregiver)
manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
I want to address the nursing diagnoses you listed although you didn't ask about them because there are errors in their construction.
acute pain must be due to some sort of physiological injury. low blood flow within the heart tissue itself, increased cardiac workload and increased oxygen consumption (of the heart tissue, I would presume, you mean) describe the nursing diagnosis of
decreased cardiac output
whose definition is
inadequate blood pumped by the heart to meet metabolic demands of the body.
if one of the patient's symptoms is pain somewhere in their body, then it is appropriate to use
acute pain
reduced cardiac output r/t inotropic changes
(1) this is not an officially titled nanda diagnosis (2)
decreased cardiac output
is the correct name (3) inotropic changes, something that changes the force of the heart's contraction is one of the related factor of
decreased cardiac output,
but I thought that was a strange way to word it. why not just say
breathlessness may be one of the defining characteristics (symptoms) of anxiety because it is a patient response, but it is not one of its related factors (causes). the definition of this diagnosis clearly states that anxiety has to do with perceived threats. breathlessness is not a threat, but threat of death is. see the nanda taxonomy information (related factors and defining characteristics) for this nursing diagnosis on these web pages:
and. . .
this patient has COPD? I am surprised not to see the two traditional nursing diagnoses for COPD patients:
impaired gas exchange r/t alveolar-capillary membrane changes
and
ineffective airway clearance r/t excessive mucus and COPD.
nanda allows the use of COPD as a related factor and does not consider it a medical diagnosis. it is a vague term that represents 4 respiratory conditions: emphysema, chronic obstructive bronchitis, chronic obstructive asthma and chronic bronchitis with emphysema. patients with one of the copds often have cardiac disease involvement--often cor pulmonale. your teaching can revolve around any of the treatments that the patient needs to be doing with relation to maintaining their pulmonary or cardiac health.
Search Care plans on google. try evolve elsvier website.( I cannot remember the EXACT addie)They have a "create a care plan". This, as well as, other sites really helped me. With the help of the site I have become an amazing care plan writer, and my instructors have asked to use my care plans as examples. MY ADVICE: remember for interventions...ask yourself "what would or did I do for this patient". Although using the sites and care plan writing books are definately helpful, ALWAYS be thinking about "real life" care!!! It will really help you! Good luck
:redpinkhe
PS. I started off HATING care plans... now my friend and I are seeking out jobs where our soul job would be to write care plans for hospitals. : )
So far I haven't had much trouble w/ care plans and I've always done relatively well on them. This one, though, I'm having a bit of trouble coming up w/ a dx for a pt.
We have just started our OB clinicals. My pt yesterday is (was) a 39-y.o.; also a gravida 14, para 7. She has a hx of DVT and it was apparent, as she was on Lovenox (sp?), which she discontinued a few days before the delivery. She also had the red mottling on her legs. I discussed this w/ my instructor, and she told me that she believes the DVT nrsg dx is the best one to go with (even though there were other issues, this one is the most emergent).
My question is the nrsng dx for the baby (and I've never done a care plan on anyone other than an adult, so I'm feeling a bit lost). Gorgeous little baby, healthy as can be, and was able to breast feed just great. Birth weight was in healthy range, zero jaundice...really, overall, her assessment was just about as perfect as can be. So what exactly can I put as a nrsng dx for her? Her parents seemed attentive and caring. The only things I can think of are somewhere along the lines of:
**Risk for Caregiver Role Strain (d/t the mom already having six other children and her socioeconomic status is, shall we say, not optimal; plus, mom's health isn't good)
**Risk for Impaired Parenting (with the same reasons listed above).
Knowing that I am required to do a NANDA-approved dx (can you do a care plan any other way?) seems like it's hemming me in. Plus, can I really apply the above dxs for the baby? Normally, wouldn't they be for the parent?
Any help that anyone can give me would be greatly appreciated!
Specializes in med/surg, telemetry, IV therapy, mgmt.
biol20fan said:
so far I haven't had much trouble w/ care plans and I've always done relatively well on them. this one, though, I'm having a bit of trouble coming up w/ a dx for a pt.
we have just started our ob clinicals. my pt yesterday is (was) a 39-y.o.; also a gravida 14, para 7. she has a hx of dvt and it was apparent, as she was on lovenox (sp?), which she discontinued a few days before the delivery. she also had the red mottling on her legs. I discussed this w/ my instructor, and she told me that she believes the dvt nrsg dx is the best one to go with (even though there were other issues, this one is the most emergent).
my question is the nrsng dx for the baby (and I've never done a care plan on anyone other than an adult, so I'm feeling a bit lost). gorgeous little baby, healthy as can be, and was able to breast feed just great. birth weight was in healthy range, zero jaundice...really, overall, her assessment was just about as perfect as can be. so what exactly can I put as a nrsng dx for her? her parents seemed attentive and caring. the only things I can think of are somewhere along the lines of:
**risk for caregiver role strain (d/t the mom already having six other children and her socioeconomic status is, shall we say, not optimal; plus, mom's health isn't good)
**risk for impaired parenting (with the same reasons listed above).
knowing that I am required to do a nanda-approved dx (can you do a care plan any other way?) seems like it's hemming me in. plus, can I really apply the above dxs for the baby? normally, wouldn't they be for the parent?
any help that anyone can give me would be greatly appreciated!
thank you, everyone! :redbeathe
think about what you know about the assessment findings of a normal newborn compared to an adult. what's different? for one thing newborns can't regulate their body temperature which is why we don't leave them exposed to the room atmosphere for very long with just a diaper covering them. that's ineffective thermoregulation r/t immature compensation for changes in environmental temperature. some newborns just have a few difficulties with excessive secretions in the respiratory track (the big hint here is that the nurses will keep a bulb syringe nearby the baby) so ineffective airway clearance can be used. if the baby has been circumcised that is another reason for a risk of infection. this baby is breastfeeding so use effective breastfeeding. they also have a stump from the umbilical cord hanging off their future belly button. do you?
FriendlyGhostRN
275 Posts
Thanks for helping out!! it cleared up some confusion I was having for sure, and also taught me a lot! ?