I Think I'm Going Insane

danissa, LPN, LVN · Jun 14, 2007

This is off topic, but I just want to say I have always wanted to visit Scotland. Is it as beautiful in real life as it is in photos?
p.s. I think it's very cool we can all communicate as students across the globe and also share common issues.

SoulShine...have sent you a pm.

WDWpixieRN, RN · Jun 14, 2007

When I've gone on the Barnes and Noble website, the Ackley/Ladwig book is definitely showing as the better seller among all the different care plan books that are listed. Strictly speaking, however, it is not a care plan book, but a nursing diagnosis reference. I have copies of both books here at home. They are both good. The Gulanick/Myers book was specifically written for students.

I know Ackley was recommended at our school as a good reference book to use. I'm not sure if it was the one carried in our bookstore as I have both this one and Spark's. Both very similar in many respects. If other instructors are recommending it, that could account for the higher sales. I don't necessarily endorse Spark's as it seemed to contain more NIC/NOC type stuff, but I was able to use it for ideas to cross-reference back to Ackley if I couldn't find something there.

smurfy · Jun 14, 2007

I think I have had all of these instructors rolled into one. just do exactly as she says for your next care plan. the more info., the better. ask her questions (even if you know the answer) so that she will think you look up to her. always make sure to thank her even if she is being a *****. these tips helped me out most of the time.

Jenny67 · Jun 14, 2007

THank you Daytonite! I have added them to my list and will be picking them up in the Fall.

:)

-Jenny

Anjann, RN · Jun 14, 2007

I came from a program that was just like that. I am not kidding when I say that I grew my first gray hairs my first semester! Once you get the recipe down for a good care plan, you'll be able to knock them out of the park with no problem, every time. You just have to make sure your rationale and your interventions are realistic and appropriate and properly referenced.

I thought the profs and the CI's who were like that were simply unkind, but now I am so glad we were put through the ringer so to speak. The truth is that when I got out I quickly discovered that I really didn't know very much at all, and alot of that training is all you will have to fall back on at first.

The good I try to take from it is that the at times paranoid attention to detail that was drilled into my brain is essential if we want to be good nurses. I can only speak from a few months experience on the floor, but already I see where paying attention to little things can be critical.

A few weeks ago I had a post-surgical patient whom I heard coughing from another patients room where I was trying to do an assessment. The cough just didn't "sound" right to me, so I excused myself and went to check on the patient. There was blood everywhere. The patient had busted some stitches and we had to rush him back to the OR. I had been in the room 10 minutes earlier and he was not visibly bleeding. For some reason he was too disoriented to call for a nurse, so I'm glad I went in there. It's not a paperwork example, but I hope this helps!

Just know that you're experience is very normal for many schools and you have to decide to not let it beat you and do whatever is necessary to succeed. I had so many friends that were dropped for as little as one percentage point. So stay on your toes and keep your ears and eyes open!

TruDivaRN, BSN, RN · Jun 14, 2007

Daytonite,

I'm sorry about not responding to your post on my MI care plan. Well let me first say for the MI care plan, I used Impaired gas exchange for my primary Dx. My reason for doing this was my client's major problem was dypsnea. I kept him in high fowlers with O2 on 4l/min. I used ineffective perfussion for my second Dx, and acute pain for my third. Needless to say, when I got my care plan back in big red words, she asks why didn't you use decreased cardiac out put??? This confused me, because in my post I told you guys that she told me that ineffective perfussion and decreased cardiac output where the same Dx. So she gave me an unsatisfactory for planning on my care plan. She said decreased cardiac output should have been my primary, not remember I had ineffective perfussion for my primary at first, followed by decreased cardiac output.

Last week I had a CAD client. I used ineffective perfussion for my primary. My second was risk for impaired skin integrity r/t hyperglycemia. My third was ineffective coping. Under my sub/obj data I put heparin drip, coumadin 5mg, I can't remember the others. Well, when I got my care plan back, she says coumadin, and heparin drip should not have been included in the sub/obj data. She again asks why didn't I use decreased cardiac output? She says my r/t hyperglycemia is a medical Dx. I should not have used ineffective coping, even though client stated several time he eas worried about wife being home alone, and why his sugars are so high now. She says I should have used impaired gas exchange because client was coughing up rust color sputum. Now mind you, I never heard this man cough not once in two days, or saw any sputum. So once again I got an unsatisfacory for planning. I'm so confused right now. HEEELLLLPPPPP!!!!!

algebra_demystified · Jun 14, 2007

My first few care plans were horrible. By second semester, my CI pulled me aside and told me that I have a problem with care plans, and I have to rewrite all of my care plans for the semester. Four 20-page care plans had to be rewritten.

I went completely over the top, getting sample care plans from the students who were held up as positive examples, and included everything that each one of them had put in their care plans. The 20 pages expanded a bit.

When I got one back that had all positive comments, I used that one as my template. I just cut and pasted a lot after that point. Whatever was different from pt to pt I changed, anything that was the same I left alone. I started up a second document for all the meds and just cut/pasted from that one to my current care plan for the meds, and changed my notes to reflect why that particular patient was getting that med.

My last 2-3 care plans were done in a quarter of the time and I got compliments on them from my CI. She was going to boot me if I didn't get my care plans up to snuff, and now they're bulletproof.

If your instructor is telling you that one ND is wrong and to use another, just do it. Amend your care plan and resubmit, asking for further correction. Why use this one over that one. What made you choose? Get your CI to explain, and then just use that CI's though process in writing your care plan.

I expect it's a little late in the game to do that with this CI. Next semester, I'm going to make an appointment to see my CI and go over my first care plan. What about this section, what about my ND, tell me about what interventions you would use in this situation. I'm not letting 3rd semester slip through my fingers.

Daytonite, BSN, RN · Jun 15, 2007

it sounds to me like your instructor might know these patients. also, these are all cardiac patients. decreased cardiac output is a diagnosis that can often be used when there is any degree of heart impairment. this is why it is good to look at a reference that shows you what nanda has to say about this diagnosis. it's definition is "inadequate blood pumped by the heart to meet metabolic demands of the body." nanda breaks the symptoms down into the categories they fit into for you, but they fall into five groups:

altered heart rate
altered rhythm
altered afterload
altered contractility
altered preload

you need to make sure that you know what the definitions of all these terms are. where there is an mi there is usually heart failure; where there is heart failure there are issues of arrhythmia and hemodynamics (afterload/preload). these guys are all in bed with each other and you have to know what these concepts are and the signs and symptoms of each. i'm betting that your instructor worked (or works) in cardiology and knows these conditions very well and understands the use of this nursing diagnosis. somewhere, your instructor saw that your patient was coughing up rust colored sputum. i'm wondering where she found that piece of data, although i have a good guess. she looked at other nurses notes or doctor's progress notes. sputum becomes rust colored because of the presence of blood due to pulmonary vein engorgement secondary to congestive heart failure. with cad which is a chronic progressive disease patients have atherosclerosis of the coronary arteries. cad progresses to an mi. and, on the way to getting there, or once there, these patients often experience arrhythmias (see #2 above), cardiogenic shock, and heart failure (see #3, 4, and 5). ineffective perfusion of the heart is included in the diagnosis of decreased cardiac output, so there is no need to also include the diagnosis of ineffective tissue perfusion: cardiopulmonary. that is what your instructor was telling you when she told you on your first care plan that ineffective tissue perfusion and decreased cardiac output were the same diagnosis. i just said it differently for you. you will use ineffective tissue perfusion with other patients who have problems such as peripheral vascular disease or tias.

my understanding of the ineffective tissue perfusion diagnosis, is that it needs to be used when the problem of oxygen perfusion involves organs other than the heart. so, when atherosclerosis is directly affecting body systems other than the heart it would be appropriate to use this diagnosis. when you are specifically referring to tissue perfusion in the heart you should use the decreased cardiac output diagnosis. if the patient also has some pulmonary involvement which is often likely you would also use impaired gas exchange because this diagnosis has to do with perfusion problems of the lung. you would use that rather than ineffective tissue perfusion: cardiopulmonary. these two diagnoses (decreased cardiac output and impaired gas exchange) kind of go hand in hand when you have any kind of congestive heart failure.

as for sequencing of those two diagnoses, you are talking about perfusion of oxygen to cells. the heart takes top priority in cardiology cases. heart cells deprived of oxygen will die off faster than lung cells deprived of oxygen. therefore, decreased cardiac output is sequenced before impaired gas exchange in these patients. that, i believe, would be her rationale for sequencing one over the other.

when i work with a nursing diagnosis that i am not familiar with, i use my little nanda reference book (nanda-i nursing diagnoses: definitions & classification 2007-2008) that has the definitions and symptoms to make sure i've classified, or grouped, my patients symptoms into the right nursing diagnosis. let me tell you about impaired skin integrity. (nanda-i nursing diagnoses: definitions & classification 2007-2008, page 199) the related factors listed for it include the following:

external
- chemical substance
- extremes in age
- humidity
- hyperthermia
- hypothermia
- mechanical factors (e.g., shearing forces, pressure, restraint)
- medications
- moisture
- physical immobilization
- radiation
[*]internal
- changes in fluid status
- changes in pigmentation
- changes in turgor
- developmental factors
- imbalanced nutritional state (e.g., obesity, emaciation)
- immunological deficit
- impaired circulation
- impaired metabolic state
- impaired sensation
- skeletal prominence

now, i can't say that i agree that hyperglycemia is strictly a medical diagnosis, it's a medical term and could probably rightfully be argued that it's a judgment call to use the term rather than to state "blood sugar of 150". but, to my way of thinking it's an awfully broad term to use and something more specific could take it's place such as "elevated blood sugar of 150". if you look at the list i just copied from page 199 of my nanda handbook you don't see "hyperglycemia" appearing on it as a related factor (that would be the r/t part of your diagnostic statement). however, if you study that list a little more closely you will see this: impaired metabolic state. that's your patient's hyperglycemia, it's etiology. the etiology is what you're after in the "r/t" part of the diagnostic statement. i don't know what your actual defining characteristics (symptoms) were to support the hyperglycemia, but your nursing diagnostic statement would have probably been a lot more acceptable to this instructor if it was written as impaired skin integrity r/t impaired metabolic state (secondary to diabetes mellitus) aeb [description of the boo-boo]. the hyperglycemia, which is a symptom of dm (diabetes mellitus) doesn't belong with this nursing diagnosis. it belongs with some other nursing diagnosis, but not this one. this diagnosis has to do with the boo-boo and getting it healed, preventing it from getting bigger, and/or protecting it.

receiving a heparin drip or coumadin are treatments ordered by the doctor. treatments are interventions. interventions do not belong in the nursing diagnostic statement. (see the links i gave you to the elements of a nursing diagnosis statement below-pes.) i understand why you got dinged for that by your instructor. that is a big boo-boo and indicates that you are not understanding how to construct a nursing diagnosis statement. the information following the words "aeb" of a nursing diagnostic statement is always your abnormal data assessment items (in actuality, your patient's symptoms) that comes from the assessment of the patient.

when you are talking about ineffective coping your patients symptoms should be worded to express their inability to assess their current situation and their lack of the ability to process information and know where to get help. for example, ineffective coping r/t situational crisis aeb statements by the patient that "i don't know what to do about my wife being home alone" and "what am i going to do about my blood sugars being so high?" the etiology (r/t part of your diagnostic statement) or reason for the patient making those statements is because of the situation they find themselves in. the problem is they are coping ineffectively, not dealing with the situation effectively, not knowing where to turn to get help or not able to realize that they merely need to ask for help.

from the information you've supplied i get the impression that the problem might lie in how you are grouping your patients symptoms into nursing diagnoses, the amount and type of data (symptoms) you are using and the actual construction of a nursing diagnostic statement. these are all elements that are primary to the formation of a care plan. however, i'm also getting the impression that your instructor is also suggesting that you missed some important assessment data (i.e., the rust colored sputum). assessment data doesn't just come from what you observed or what the patient told you. there's a lot more to it that that. i was recently reading that only about 10% comes from what we actually observe from the patient. the remaining 90% we get from the patient's medical record and what other healthcare providers discovered as well. when i first read this i was astonished at the percentages, but as i thought about it i began to realize she was right. when i was a practicing staff nurse, i would often look at key documents in my patient's charts (h&ps, surgical reports, labwork, x-ray reports) as well as perform my own physical assessment on patients. all of that combined with my knowledge of the pathophysiology of their medical diseases comes together to develop the plan of care. now, on the job, all that information is put together in our brains in a matter of minutes (this is critical thinking). however, for school you are asked to demonstrate this by doing it on paper which significantly slows the speed of the process. another student recently asked what they should be doing to prepare for their clinical patient. i listed the things in the patient's chart they should be getting information from. you might want to print this post out as a guideline for yourself: https://allnurses.com/forums/2228927-post5.html. also, you need to be very clear in your mind what the elements of the nursing diagnostic statement are (pes--problem, etiology, symptoms). i have posted this information in a number of different threads:

one of the reasons instructors can make students feel intimidated with their criticisms of their care plans is because students don't have a good foundation and understanding of the process that underlies the care plan process. and why should you? this is all brand new information that none of you have ever seen before. in many cases, you have no experience to even draw from to equate it with. assessment and determining the nursing diagnoses are two that i find are the biggest problem areas. if you don't know the right questions to ask and the instructor isn't forthcoming in providing you with feedback, you feel lost. contrary to what some may think, this whole care plan writing business and nursing process in action is a very complex and highly evolved activity that takes a long time to learn. don't give up. like any other nursing skill, and make no mistake about it, this is a skill, it takes practice, practice, practice. that means you have to write many of them in order to get good at it. hang in there.

Daytonite, BSN, RN · Jun 15, 2007

My first few care plans were horrible. By second semester, my CI pulled me aside and told me that I have a problem with care plans, and I have to rewrite all of my care plans for the semester. Four 20-page care plans had to be rewritten.
I went completely over the top, getting sample care plans from the students who were held up as positive examples, and included everything that each one of them had put in their care plans. The 20 pages expanded a bit.
When I got one back that had all positive comments, I used that one as my template. I just cut and pasted a lot after that point. Whatever was different from pt to pt I changed, anything that was the same I left alone. I started up a second document for all the meds and just cut/pasted from that one to my current care plan for the meds, and changed my notes to reflect why that particular patient was getting that med.
My last 2-3 care plans were done in a quarter of the time and I got compliments on them from my CI. She was going to boot me if I didn't get my care plans up to snuff, and now they're bulletproof.
If your instructor is telling you that one ND is wrong and to use another, just do it. Amend your care plan and resubmit, asking for further correction. Why use this one over that one. What made you choose? Get your CI to explain, and then just use that CI's though process in writing your care plan.
I expect it's a little late in the game to do that with this CI. Next semester, I'm going to make an appointment to see my CI and go over my first care plan. What about this section, what about my ND, tell me about what interventions you would use in this situation. I'm not letting 3rd semester slip through my fingers.

I understand your situation and that passing is important, but you don't really understand why these things are working, do you? Doesn't that bother you? It would me.

tutored · Jun 15, 2007

I totally agree with Daytonite's recommendation of the Ackley careplan book - I only wish I would have gotten it at the beginning of school (I'm done at the end of the year)....the ackley book is worth all 7 of my other careplan books combined. Do get it!

JarOfPennies · Jun 15, 2007

Daytonite, I have learned so many helpful things from you! Thanks for being so generous with your knowledge and recommendations. I'll be starting nursing school in the fall and all of this will, hopefully, help me to prepare. You are great!

Lisa CCU RN, RN · Jun 17, 2007

Daytonite, I have learned so many helpful things from you! Thanks for being so generous with your knowledge and recommendations. I'll be starting nursing school in the fall and all of this will, hopefully, help me to prepare. You are great!

:yeahthat: :yeahthat: :yeahthat: