I am doing my first care plan and I have a question

[Jenn_RN]

We are doing our first care plans this week and I want to make sure I am going in the right direction. Any advice would be GREATLY appreciated, as I feel like we've been thrown in the water with no life preserver and I am not sure what to do!

Okay, my patient (61 F) has Diabetes, and has had it since she was pregnant with her first child. She has a lot of complications that have gradually developed over the years, but by talking with her, I don't get the impression that it is due to her negligence of care, rather I think it's just the progression of the disease. She eats the correct diet, takes her insulin and medications on time, etc.

Anyway, so there's that. Her existing complications include hypertension, renal insufficiency, Charcot's joint Disease, Diabetic retinopathy and diabetic neuopathy, erosive esophagitis w/ ulcers. She was admitted with nausea, vomiting and diarhea, all of which was resolved after receiving an enema. She was diagnosed with gastroparesis. Soooooo,

nursing diagnosis -- I DON'T KNOW! I am trying so hard to figure this out, I have all 4 books in front of me, and I can't figure this out. I know that it means "decreased gut motility", but I can't find that as a nursing diagnosis, so I know that can't be right to just write that in. Would it be nausea, vomiting or diarrhea? but which is most important to choose it to be the nursing diagnosis?

Please, I don't want anyone to do my work, but if someone can help me, give me a little shove in the right direction, it will save me so much frustration. :) I thank you so much.

[RNConnieF]

One way to get around the no medical dx is to say R/T "disease , process". I'm pretty sure the decreased gastric motility would fly it's not a diagnosis. For diabetes you would have to say something about "ineffective metabolism of carbohydrates". It sounds silly but it works. As for interventions, you should be basing ALL your nursing care on a care plan, even if it's in your head, all the time. As you go on in the program you'll have to turn in your care plan at the end of the clinical day so start thinking now about using care plans in practice and not just as a paper that's due. It comes with practice, and I'm sure you're already doing it. When you first meet your diabetic pt. you know right away that diet teaching is going to be a priority-that's using a care plan. See, it's not as hard as it looks.

[EMTPTORN]

several nursing diagnosis come to mind:

Ineffective protection (several different reasons)

Risk for injury (due to neuropathy)

Impaired skin integrity (ALL diabetics are at minimum at risk for this)

Look in your care plan books and they will have key points/assessment clues that you will find that quantify the nursing dx. So, with practice come up with nursing dx you think is right, then see if the pts' P.E. matches this dx.

Remember to pick the most important nursing dx for "life"

Remember your ABC's...

Also if you organize via Maslows hiarchy and pick things at the base or foundation of the pyramid, you usually cannot go wrong.

Don't be discouraged....we all go through what you are going through, and in time it will come a lot easier.

Regards

[Love-A-Nurse]

"break the medical dx down to the s/s to get your nursing dx, is one way of doing it.

let us know how it goes.

[KRVRN, BSN, RN]

Risk for Infection and Anxiety are just about always applicable to any pt in the hospital.

[rosemadder]

I find that the best way to write a care plan is to keep it as simple as possible.

For example: after assessing my patient and determining their problems-I ask myself what is the most critical problem at that moment and then start my care plan with that. And I put interventions that I as a student can easily do such as assess q whatever, Give pain meds timely manner, Turn q2h/prn, Develop therapeutic relationship, etc. Be sure and don't write your care plan on the disease but on the problems evidenced. In other words, people with diabetes may have all kinds of problems but the only ones you are addressing in your care plan are the ones you are going to take care of personally. Only use a "risk for" if there is a reason that you feel they are at risk. For example, a diabetic is at risk for feet problems but if your patient takes very good care of their feet and have no problems in that area--then don't address it. My favorite care plan book is by Ackley-Ladwig, 5th edition, can't recall the name but it is wonderful. One good care plan book is worth its weight!

Good luck!

[NICU_Nurse, BSN, RN]

Off the top of my head, these are the ones I thought of that might apply to her:

---Related to the esophogeal erosion:

Altered Nutrition (less than body requirements; good if she's NPO, not eating because it's uncomfortable, on TPN/PIA/IV nutrition or lipids, or has had weight loss related to her illness, which diabetics frequently do).

Impaired Swallowing

Altered Oral Mucous Membrane

Acute Pain (this is very painful!)

---Related to the N/V/D:

Risk for Fluid Volume Deficit

Diarrhea

---Related specifically to the diabetes:

Risk for Injury or Infection (cased by either the neuropathy, for instance, she steps on a piece of glass and can't feel it and it erodes into a sore, or the retinopathy, because her sight is impaired and she could injure herself that way)

Health Seeking Behaviors or Knowledge Deficit- state specifically what it is. (if she's looking to improve her health status; this is an easy one. Just about everyone can qualify for this diagnoses, and it helps you incorporate teaching into your interactions with the patient)

You asked about lab tests... When I was writing mine (granted, I've been out of school for a year now, so forgive mistakes!), I always included lab tests, but phrased like,

Draw CBC, BMP, and other applicable lab samples per MD order.

That way I could include it in my careplan, but I wouldn't necessarily *do* it unless it was ordered.

[essarge]

We put the medical diagnosis secondary to the relative to...example....Pain R/T Joint stiffness secondary to Charcot's Joint Disease as evidenced by client stating "my knees hurt a lot when I try to stand".

As far as nursing interventions, we are only allowed to put what the nurse would do. Teaching goes into a totally separate category and includes the patient and the family.

Hope this helps.

[emily_mom]

Originally posted by RNwannabeJEN

Connie, are you serious, b/c I thought yours was WAY better! I was going to ask your permission in using the lab values aspect, but I wanted to ask, do nurses need dr persmission to draw labs, or is that something we can do independantly? Your short term goals were AWESOME, much better than what I could come up with. May I use a variation of what you offered me as an example? Thank you so much for your patience and help, I bet as I do thi snext time it'll come easier, and then easier still. (At least, that's what I am hoping for!!)

For us, things like drawing labs can be included in our interventions and outcomes.

If a medical dx is needed in order to accurately write a nursing dx, we are allowed to put 'secondary'

... Nutrition: imbalanced, less than body requirements RT decreased gastric motility AEB nausea, vomiting, diarrhea secondary to Diabetes and Gastroparesis.

That's OK with our instructors. I like work SO much better! You just pick a disease and nursing dx and the computer spits out the rest....

Kristy

[Jenn_RN]

Thank you all so much for your help. I got my careplan back and it was perfect! I got an "excellent", and she also wrote on there that I filled it out appropriately and properly. There was not a single mark on it for correction (and I know she woul dhave if I had done something wrong or missed something -- she is very thorough). Thanks again, I am encouraged about this careplan stuff! :)