Help with nursing care plans!

jadelpn, LPN, EMT-B · Feb 27, 2015

It is really, really confusing. There are a few care plans that are general to most diagnosis.

"Alteration in health maintenance" is one and can discuss the lifestyle changes one would have to make to function well with diabetes.

All could get a "discharge care plan" and can discuss a patient, for instance, who could see a dietician as and outpatient.

Skin care is also huge. (Risk of alteration of skin integrity)

Also if the patient is a fall risk (and some could argue that is all patients) a fall prevention care plan.

Best wishes!

OMMx3, BSN, LPN, RN · Feb 27, 2015

It is really, really confusing. There are a few care plans that are general to most diagnosis.
"Alteration in health maintenance" is one and can discuss the lifestyle changes one would have to make to function well with diabetes.
All could get a "discharge care plan" and can discuss a patient, for instance, who could see a dietician as and outpatient.
Skin care is also huge. (Risk of alteration of skin integrity)
Also if the patient is a fall risk (and some could argue that is all patients) a fall prevention care plan.
Best wishes!

Thank you so much! I appreciate it ðŸ˜Š

Esme12, ASN, BSN, RN · Feb 27, 2015

Here is an excellent thread about nursing care plans and how to think about them......https://allnurses.com/nursing-student-assistance/care-plan-help-975504.html

Lets start at the beginning.....Care plans are all bout what the patient needs right now and are based on your assessment.

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, 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)

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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 careplan 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. Although your patient isn't real you do have information available.

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 is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."
"Related to" means "caused by," not something else.

Now here are some sheets for you to use to organize your thoughts and information from Daytonite (rip).....

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

Esme12, ASN, BSN, RN · Feb 27, 2015

Hi everyone!
I am in the very beginning of my nursing program and I am having a hard time with creating a nurses care plan. I understand why we have to make one, the problem I am having mostly with this is finding the nurses diagnosis and how to choose from the Nanda list. For example a patient with a medical diagnosis such as diabetes, what would the nurses diagnosis be? I hope I'm not the only student that found this confusing.
I appreciate all the help!
Thank you

So the patient has diabetes but has been admitted with SOB, fever and pneumonia with elevated glucose.

Lets say your assessment reveals that the patient has an elevated WBC with a left shift. Your patient is flushed, febrile T102.1F, tachypneic RR30, complaining of SOB O2 Sat 89%, HR 124. CXR reveals infiltrates bilaterally. Lytes WNL Bun 45 Creatine 1.3 Glucose 280. Patient c/o feeling hot and sweaty, a productive cough that is difficult to cough up sputum and it makes them more SOB. Describes sputum as thick and greenish yellow. You note that the patient's urine is very concentrated dark yellow and the tongue is dry lips cracked. You note that the patient cannot speak in complete sentences. Circumoral pallor is present. The patient is restless/anxious, nail beds are dusky with breath sounds diminished with bilateral coorifice rhonchi throughout lung fields.

What would you think this patient needs?

Looking at NANDA each diagnosis has a set of symptoms that applies to that diagnosis. The patient needs to have at least one symptom from the sections to use for your patient. You prioritize them by what can kill the patient first....ABC's, and Maslows.

For example. I am concerned for this patients respiratory status he appears SOB, low O2 sat and a cough that cause him to become SOB and unable to catch his breath to expel thick tenacious sputum.

I am concerned about his ability to clear his airway and this patients oxygen Sat.

According to NANDA ineffective airway clearance is defined as an Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Defining characteristics: Absent cough; adventitious breath sounds (rales, crackles, rhonchi, wheezes); changes in respiratory rate and rhythm; cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum; orthopnea; restlessness; wide-eyed

Related to:

Environmental: Secondhand smoke; smoke inhalation; smoking; Obstructed Airway: Airway spasm; excessive mucus; exudate in the alveoli;foreign body in airway; presence of artificial airway; retained secretions; secretions in the bronchi

Physiological: Allergic airways; asthma; COPD; hyperplasia of the bronchial walls; infection; neuromuscular dysfunction

So what about this patient (your assessment) fits into this definition (the evidence that this patient has an ineffective airway clearance)

the patient has an elevated WBC with a left shift. Your patient is flushed, febrile T102.1F, tachypneic RR30, complaining of SOB O2 Sat 89%, HR 124. CXR reveals infiltrates bilaterally. Lytes WNL Bun 45 Creatine 1.3 Glucose 280. Patient c/o feeling hot and sweaty, a productive cough that is difficult to cough up sputum and it makes them more SOB. Describes sputum as thick and greenish yellow. You note that the patient's urine is very concentrated dark yellow and the tongue is dry lips cracked. You note that the patient cannot speak in complete sentences. Circumoral pallor is present. The patient is restless/anxious, nail beds are dusky with breath sounds diminished with bilateral coorifice rhonchi throughout lung fields.

Esme12, ASN, BSN, RN · Feb 27, 2015

You are also worried about the O2 sat (oxygenation)....so what is affecting the O2 Sat? They have impaired gas exchange from the thick secretions, infection and pneumonia in bilateral lung fields, right?

NANDA states impaired gas exchange is defined as: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

defining characteristics: Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances

related to (as caused by): Ventilation-perfusion imbalance; alveolar-capillary membrane changes

Esme12, ASN, BSN, RN · Feb 27, 2015

Your patient is also febrile.

NANDA describes hyperthermia as: Body temperature elevated above normal rangeElevated body temperature can be either fever (pyrexia) or hyperthermia. Fever is a regulated rise in the core body temperature to 1Â° to 2Â° C higher than the client's normal body temperature as an innate immune response to a perceived threat and is regulated by the hypothalamus. Hyperthermia is an unregulated rise in body temperature that occurs when a client either gains heat through an increase in the body's heat production or has developed an inability to effectively dissipate heat

Defining characteristics: Flushed skin; increase in body temperature above normal range; tachycardia; tachypnea; warm to touch; seizures in children

Related to: Anesthesia; decreased perspiration; dehydration; exposure to hot environment; inappropriate clothing; increased metabolic rate; medications; trauma; neurological disorder/injury; strenuous physical activity in hot climates.

OMMx3, BSN, LPN, RN · Feb 27, 2015

Thank you so much for taking the time and explaining this to me. The way this was taught in class was very overwhelming and confusing. I was given a paper assignment to make a care plan on a fictional patient, however I'll be starting clinicals soon and will have to create another care plan on a real assigned patient in an LTC center so I wanted to feel 100 % confident in my care plans.

Esme12, ASN, BSN, RN · Feb 27, 2015

All sources for NANDA is Ackley: Nursing diagnosis handbook and NANDA 2015-2017

His B/P is low so you are concerned about a decrease of cardiac output. He is tachycardic, sweaty, radial pulse is weak to palpation. NANDA describes decreased cardiac output as: Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body

Defining characteristics:

Altered Heart Rate/Rhythm

Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload

Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload

Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings

Altered Contractility

Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional

Anxiety; restlessness

Related Factors (r/t) Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

Now his fluid status....you noted that his lips are dry and cracked

Deficient fluid volume: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level

Defining characteristics: Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness

related to: Active fluid volume loss; failure of regulatory mechanisms

now you have risk of unstable glucose.........

Esme12, ASN, BSN, RN · Feb 27, 2015

Thank you so much for taking the time and explaining this to me. The way this was taught in class was very overwhelming and confusing. I was given a paper assignment to make a care plan on a fictional patient, however I'll be starting clinicals soon and will have to create another care plan on a real assigned patient in an LTC center so I wanted to feel 100 % confident in my care plans.

Do you see how I used the "patient" assessment to develop a plan of care by what the patient needs?

What care plan resources do you have?

Esme12, ASN, BSN, RN · Feb 27, 2015

So use your patient assessment: the patient has an elevated WBC with a left shift. Your patient is flushed, febrile T102.1F, tachypneic RR30, complaining of SOB O2 Sat 89%, B/P 98/50,HR 124. CXR reveals infiltrates bilaterally. Lytes WNL Bun 45 Creatine 1.3 Glucose 280. Patient c/o feeling hot and sweaty, a productive cough that is difficult to cough up sputum and it makes them more SOB. Describes sputum as thick and greenish yellow. You note that the patient's urine is very concentrated dark yellow and the tongue is dry lips cracked.

You note that the patient cannot speak in complete sentences. Circumoral pallor is present. The patient is restless/anxious, nail beds are dusky with breath sounds diminished with bilateral coorifice rhonchi throughout lung fields.

Think if this was your family what would be important for them?

To breath easier, Lower their temp, give them fluids, and you want them to get that stuff out of their lungs.

Esme12, ASN, BSN, RN · Feb 27, 2015

Thank you so much for taking the time and explaining this to me. The way this was taught in class was very overwhelming and confusing. I was given a paper assignment to make a care plan on a fictional patient, however I'll be starting clinicals soon and will have to create another care plan on a real assigned patient in an LTC center so I wanted to feel 100 % confident in my care plans.

Look up your disease process. What are the complications? What meds are they on? What are the implications of the meds? Like Lasix and potassium. Lanoxin can become toxic. Heparin can cause the to bleed. What is the patients present complaints....what do they think they need.

Seriously use these sheet to collect your data....it will all start to make sense.

critical thinking flow sheet for nursing students

student clinical report sheet for one patient