I need HELP UNDERSTANDING CARE PLANS PLEASE!!!

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I am a new student, this is my first care plan, I don't understand how to put it together. I know the more I do them the more I will understand them, but when you are new it's like learning a foreign language. Can someone please have mercy on me? If I could get an example of how this should look I would really appreciate it.

Here is the scenario:

Romel Jones is an 11-month-old infant who was seen this week at the developmental pediatrician's office and was diagnosed with spastic cerebral palsy. He was referred by the pediatrician's office because he is not rolling or attempting to sit. He has hypertonia of the lower extremities. Romel is the fourth child of a 26-year-old single mother, who developed preeclampsia. He was born at 24 weeks gestation with a birth weight of 1 pound 4 ounces, and spent 3 months in the neonatal ICU, where his treatment included mechanical ventilation and tube feedings. When he was discharged home 8 months ago, he was on an apnea monitor, receiving bronchodilator medication via nebulizer, and was taking bottle feedings. His weight gain has been slow but steady, and currently he weighs 15 pounds and is 26 ½ inches long. Romel is seen monthly by a public health nurse, who has been assessing his health status and development, and teaching his mother about using a nebulizer. Romel's mother is very upset at hearing his diagnosis. She states she knew they were going to follow him for possible developmental problems, but that she had not heard anything about cerebral palsy before.

I have a nursing diagnosis of Risk for ineffective parenting but the related to and all that I am confused. Once I see it I can comprehend it. All my instructor does is tell me where I am wrong. She is not explaining to me how this should be done, this is why I am a student I am trying to LEARN. PLEASE HELP ME. I REALLY WANT TO BE GOOD AT THIS, THIS IS THE BASIS OF NURSING (WELL ONE OF THEM ANYWAY).

THANKS in advance

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

multiple threads merged and moved to nursing student assistance for best response.

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risk for impaired parenting for diagnosis sorry

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

give me a minute.....I'll reply....:).......Ok.....You are falling into the same trick bag that all students fall into.....picking you diagnosis and trying to fit the patient into it......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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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

  1. 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)
  2. 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)
  3. Planning (write measurable goals/outcomes and nursing interventions)
  4. Implementation (initiate the care plan)
  5. 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 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. 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.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

To start........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/care map: ADPIE.

  1. 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)
  2. 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)
  3. Planning (write measurable goals/outcomes and nursing interventions)
  4. Implementation (initiate the care plan)
  5. Evaluation (determine if goals/outcomes have been met)

Ok real life application paraphrased from our Beloved Daytonite.....

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).

Does this make more sense? Can you relate to that? That's about as simple as the nursing process can be simplified 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.

critical thinking involves knowing:

  • the proper sequence of steps in the nursing process
  • the normal anatomy and physiology of the human body
  • how the normal anatomy and physiology are changed by the medical and disease process that are going on
  • the normal medical treatment that the doctor(s) are likely to order to treat the medical and disease process going on
  • the nursing interventions that you have learned for the things that support the medical and disease process that is going on
  • making the connection (this is the critical thinking part) between the disease, the treatment and the nursing interventions and where on the sequence of the nursing process you are .....check out this thread.

https://allnurses.com/nursing-student-assistance/nursing-diagnosis-pt-888392.html

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I am a new student, this is my first care plan, I don't understand how to put it together. I know the more I do them the more I will understand them, but when you are new it's like learning a foreign language. Can someone please have mercy on me? If I could get an example of how this should look I would really appreciate it.

Here is the scenario:

Romel Jones is an 11-month-old infant who was seen this week at the developmental pediatrician’s office and was diagnosed with spastic cerebral palsy. He was referred by the pediatrician’s office because he is not rolling or attempting to sit. He has hypertonia of the lower extremities. Romel is the fourth child of a 26-year-old single mother, who developed preeclampsia. He was born at 24 weeks gestation with a birth weight of 1 pound 4 ounces, and spent 3 months in the neonatal ICU, where his treatment included mechanical ventilation and tube feedings. When he was discharged home 8 months ago, he was on an apnea monitor, receiving bronchodilator medication via nebulizer, and was taking bottle feedings. His weight gain has been slow but steady, and currently he weighs 15 pounds and is 26 ½ inches long. Romel is seen monthly by a public health nurse, who has been assessing his health status and development, and teaching his mother about using a nebulizer. Romel’s mother is very upset at hearing his diagnosis. She states she knew they were going to follow him for possible developmental problems, but that she had not heard anything about cerebral palsy before.

I have a nursing diagnosis of Risk for ineffective parenting but the related to and all that I am confused. Once I see it I can comprehend it. All my instructor does is tell me where I am wrong. She is not explaining to me how this should be done, this is why I am a student I am trying to LEARN. PLEASE HELP ME. I REALLY WANT TO BE GOOD AT THIS, THIS IS THE BASIS OF NURSING (WELL ONE OF THEM ANYWAY).

THANKS in advance

I have highlighted what I think are the important parts of the assessment.

This is tough because there isn't really a physical assessment and care plans depend on physical assessment for the "proof" of what the patient needs.

Do you have a care plan book? Do you have the NANDA I book for nursing diagnosis and definitions? What are you using to you ND reference?

Every ND has a definition and a list of "symptoms/proof" that go along with it.

For example: Here are two I see right off the bat.......

Delayed Growth and Development:

NANDA defines this as......Deviations from age-group norms

Defining Characteristics: Altered physical growth; decreased response time; delay in performing skills typical of age group; difficulty in performing skills typical of age group; flat affect; inability to perform self-care activities appropriate for age; inability to perform self-control activities appropriate for age; listlessness

Related Factors (r/t): Effects of physical disability; environmental deficiencies; inadequate caretaking; inconsistent responsiveness; indifference; multiple caretakers; prescribed dependence; separation from significant others; stimulation deficiencies

You know this baby fits this diagnosis because he....

he is not rolling or attempting to sit

hypertonia of the lower extremities

related to.......

being diagnosed with spastic cerebral palsy

born at 24 weeks gestation with a birth weight of 1 pound 4 ounces

So this baby has a nursing diagnosis of.....

delayed growth and development R/T(related to) being born at 24 weeks gestation, a low birth weight of 1lb 4oz and a recent diagnosis of cerebral palsy AEB (as evidenced by) baby is not rolling over or attempting to sit and hypertonia of the lower extremities.

But you need to know a few things first and look them up. What is Spastic Cerebral palsy? What causes Cerebral Palsy? What is the "normal" milestones for this age group? How much should baby weigh at this age? How does cerebral palsy affect this babies feeding?

The other I see is........Ineffective infant Feeding Pattern.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

RISK of IMPAIRED PARENTING: defined as risk for inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child.

Defining Characteristics: (Specify: lack of parental attachment behaviors, verbalization of resentment toward child and of role inadequacy, inattention to needs of child, noncompliance with health practices and medical care, inappropriate discipline practices, frequent accidents and illness of child, growth and development lag in child, history of child abuse or abandonment, multiple caretakers without regard for needs of child, evidence of physical and psychological trauma, actual abandonment of child.)

Infant/child

Poor academic performance; frequent illness; runaway; incidence of physical and psychological trauma or abuse; frequent accidents; lack of attachment; failure to thrive; behavioral disorders; poor social competence; lack of separation anxiety; poor cognitive development

Parental

Inappropriate child care arrangements; rejection of or hostility to child; statements of inability to meet child's needs; inflexibility in meeting needs of child or situation; poor or inappropriate caretaking skills; regularly punitive; inconsistent care; child abuse; inadequate child health maintenance; unsafe home environment; verbalization of inability to control child; negative statements about child; verbalization of role inadequacy or frustration; inappropriate visual, tactile, auditory stimulation; abandonment; insecure or lack of attachment to infant; inconsistent behavior management; child neglect; little cuddling; maternal-child interaction deficit; poor parent-child interaction

Related Factors: (Specify: unmet social and emotional maturation needs of parental figures, ineffective role modeling, lack of knowledge, situational crisis or incident.)

Social : Lack of access to resources; social isolation; lack of resources; poor home environment; lack of family cohesiveness; inadequate child care arrangements; lack of transportation; unemployment or job problems; role strain or overload; marital conflict, declining satisfaction; lack of value of parenthood; change in family unit; low socioeconomic class; unplanned or unwanted pregnancy; presence of stress (e.g., financial, legal, recent crisis, cultural move); lack of or poor parental role model; single parent; lack of social support network; father of child not involved; history of being abusive; history of being abused; financial difficulties; maladaptive coping strategies; poverty; poor problem-solving skills; inability to put child's needs before own; low self-esteem; relocations; legal difficulties

Knowledge : Lack of knowledge about child health maintenance; lack of knowledge about parenting skills; unrealistic expectations for self, infant, partner; limited cognitive functioning; lack of knowledge about child development; inability to recognize and act on infant cues; low educational level or attainment; poor communication skills; lack of cognitive readiness for parenthood; preference for physical punishment

Physiological

Physical illness

Infant/child : Premature birth; illness; prolonged separation from parent; not desired gender; attention deficit hyperactivity disorder; difficult temperament; separation from parent at birth; lack of goodness of fit (temperament) with parental expectations; unplanned or unwanted child; handicapping condition or developmental delay; multiple births; altered perceptual abilities

Psychological : History of substance abuse or dependencies; disability; depression; difficult labor and/or delivery; young age, especially adolescent; history of mental illness; high number of or closely spaced pregnancies; sleep derivation or disruption; lack of or late prenatal care; separation from infant/child

Ackley: Nursing Diagnosis Handbook, 10th Edition (Resources)

How does this parent fit these definitions?

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Oh Esme. ❤

I feel your pain, OP. I struggled immensely with care plans this semester...my second semester of doing them! I ended up requesting a private session with my course coordinator which ended up being much more helpful than her class review had been. Esme's posts are right on, and so thought out. Scour them, print them, save them. She is an invaluable resource with care plans! I've got stuff on file from her posts. ;)

Try breaking down the care plan into separate parts. Sometimes sitting and looking at it as a whole can be so overwhelming, for me at least. Finding the diagnosis that fits best can sometimes be the hardest part. Once you've got that, the rest can flow out. Be specific in your data, and in your interventions. If you need an example of a completed care plan, I'd he happy to email you one that my professor printed for me. It helps to see one laid out so you can get a game plan. Good luck! They get easier.

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I am using Mosby's nursing diagnosis book. I understand what you are saying.(I think). So my nursing diagnosis should be Delayed Growth and Development related to being diagnosed with spastic cerebral palsy born at 24 weeks gestation with a birth weight of 1 pound 4 ounces. A measurable patient outcome would be: Achieve realistic developmental/and or growth milestones based on existing abilities, extent of disability, and functional age. Criteria to establish this outcome has been met is: provide parents/and or caregivers realistic expectations for attainment of growth and development milestones. Clarify expectations and correct misconceptions. Is this correct so far? Thank you for taking the time to help me, I really, really, really appreciate it.

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I would love for you to send me a care plan. I am just starting.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I can post care plan examples....I don't send completed care plans.....You need to do it yourself.....but what format does your school want?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I posted your ND......

So this baby has a nursing diagnosis of.....

delayed growth and development R/T(related to) being born at 24 weeks gestation, a low birth weight of 1lb 4oz and a recent diagnosis of cerebral palsy AEB (as evidenced by) baby is not rolling over or attempting to sit and hypertonia of the lower extremities.

based on this criteria .....from Grntea....

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.

http://www.pterrywave.com/Nursing/Care Plans/Nursing Care Plans TOC.aspx
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