Help with 1st Care Plan

Esme12, ASN, BSN, RN · Apr 3, 2012

i am trying to write my first care plan for a real patient. i have to fill out a pathophysiology sheet on the "client's primary admitting medical disease/disorder. my patient is in a rehab facility post surgery for a total hip replacement. she is she is 10 days post op. the principle admitting medical diagnosis to the rehab facility is "aftercare f/surgery musculoskeletal system nec.
the hip replacement is due to osteoarthritis. the following medical diagnosis's are type 11 diabetes, gen osteoarthritis involving multiple sites, hypertension, hyperlipidemia.
should i use the osteoarthritis as the medical diagnosis and do my path sheet on this? the aftercare.... isn't something i can get from a patho book. i am confused.
thank you.

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) https://allnurses.com/general-nursing...ns-286986.htmlyou can also use the search on this site to lead you to care plans.

https://allnurses.com/lpn-lvn-nursing/i-need-help-665349.html great advice here as well.

daytonite.

care plan basics:

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

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:

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)

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.

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.

care plan reality: 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). [thanks daytonite]

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.

you must have a care plan book. now for the pathophysiology. your patient has diabetes type ll, htn(hypertension), hyperlipidemia, and osteoarthritis. does your instructor want all disease processes pathophysiology or just the one that relates to the reason for the hip replacement.

for pathophys your book will help immensely but so will the internet.

osteoarthritis.....

osteoarthritis - mayoclinic.com, osteoarthritis - pubmed health, medscape: medscape access you need to register for medscape but it is free, no strings, and a huge resource for you.

diabeties type ll.......

medscape: medscape access

hypertension....

medscape: medscape access

ok? now the care paln

Esme12, ASN, BSN, RN · Apr 3, 2012

did you talk to your patient. what were her complaints. what would be affected by having this surgery, as least temporarily.

can she perform adls without assistance? (self care deficit) is she still having pain?(acute pain) how does she ambulate? (impaired mobility) are there any signs of infection? does she know about her hip replacement and rehab? (deficient knowledge) does she have chronic pain from her osteoarthritis? does impaired mobility make here at risk for falls and her safety?

these resources may help.

nursing care plan

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

questions?

nurseprnRN, BSN, RN · Apr 3, 2012

she's there because she has had a hip replacement surgery and needs to regain strength to return home. she also has type ii (that's "two," not "eleven") diabetes, which will make her prone to some complications.

look up hip replacement in your textbook or online (use a reputable site like a university hospital orthopedics department patient teaching area), and read up on diabetes. you will see diabetic patients for the rest of your professional life, no matter what area of nursing you work, so you might as well start learning as much as you can about it.

Witty3RN · Apr 4, 2012

I am trying to write my first care plan for a real patient. I have to fill out a Pathophysiology Sheet on the "client's primary admitting medical disease/disorder. My patient is in a rehab facility post surgery for a total hip replacement. She is She is 10 days post op. The principle admitting medical diagnosis to the Rehab facility is "aftercare f/surgery musculoskeletal system NEC.
The hip replacement is due to osteoarthritis. The following Medical diagnosis's are Type 11 diabetes, Gen osterarthrosis involving multiple sites, Hypertension, Hyperlipidemia.
Should I use the osteoarthritis as the Medical diagnosis and do my path sheet on this? The aftercare.... isn't something I can get from a patho book. I am confused.
Thank you.

In our nursing school we are never allowed to use a medical diagnosis for a nursing diagnosis. I'm thinking something like impaired physical mobility related to surgical procedure.

And some of the interventions could be: Teach the patient about weight-bearing restrictions, Instruct the patient in the use of mobility aids(walker), Assess muscle strength, coordination, and ability to use mobility aid (per physical therapist), and such. Or the patient may still be having problem with pain and then pain could be the focus of your care plan.

nurseprnRN, BSN, RN · Apr 4, 2012

no, the medical diagnosis isn't the nursing diagnosis. but it can be a defining characteristic; if you have looked un your nanda-i 2012-2014 you will see quite a few nursing diagnoses with one of the defining characteristics = "disease process."

this does not mean that there is a magic list of medical diagnoses from which you can derive nursing diagnoses. nothing is farther from the truth.

yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology. i'm pretty sure i will probably see a constellation of nursing diagnoses related to these effects, and i will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. i might find readiness to improve health status, or ineffective coping, or risk for falls, too. these are all things you often see in diabetics who come in with complications. they are all things that nursing treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. but i can't put them in any individual's plan for nursing care until *i* assess for the symptoms that indicate them, the defining characteristics of each.

medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

so, you don't think of a diagnosis for your patient and then go searching for supporting data. you collect data and then figure out a nursing diagnosis.

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

pinksapphire · Apr 7, 2012

Thank you so much for the help. I was up all night but I got it written. Hopefully it won't be too marked up when I get it back. This week's care plan should go a little quicker (I hope).