Last written project- need help wording plan, PLEASE

Daytonite, BSN, RN · Sep 5, 2007

Collaborative care are interventions or doctor's orders that are carried out by other members of the healthcare team, or collaborators. A collaborator is a person who works together in cooperation with another. Collaborators on the healthcare team include social workers, physical therapists, dieticians, respiratory therapists, pharmacists, doctors, nurses, speech therapists and many others. There are many different licensed positions that give care to patients that nurses cannot do. Doctors will order this care and these other professionals will perform it. Nurses, however, will, as managers of patient care, make sure that these professionals know about the doctor's orders and that the doctor's wishes are directed to these other professionals. Sometimes nurses will ask that these professional see and evaluate a patient because they might feel that the patient may benefit from the services they could offer. This is all collaborative care.

After reading the information you have given about your patient, I can't say that I agree with your choice of nursing diagnoses and I am puzzled that your instructor would have approved them. "Risk for" diagnoses are problems that don't even exist, but only anticipated that they might happen. And, I don't know how you determined that this patient was noncompliant because you give no evidence that this child isn't going to follow the plan of care that the doctor orders.

A care plan is supposed to address actual problems that a patient has. According to the information you have provided, your patient has two very valid symptoms: nausea and diarrhea. Because of them the doctor ordered treatment for them as well as for the parasitic infection. Nursing diagnoses are ALWAYS based upon the symptoms a patient has. Those are determined from the assessment that you have made of the patient (physical exam, interview and review of the medical record). That is ALWAYS what guides and determines the nursing diagnoses you decide upon.

There is one nursing diagnoses that would apply here that I think needs to be mentioned:

Diarrhea R/T infectious process due to Cryptosporiosis AEB [patients symptoms go here--examples would be abdominal pain, X loose liquid stools per day, cramping, hyperactive bowel sounds, urgency, irritated skin around rectum]
- your goals for this are to quite simply the reverse of the symptoms, i.e. to have a normal, formed stool daily, for abdominal pain and cramping to be relieved or for the skin around the rectal area to be intact and free of redness and irritation. The way this occurs is for you plan to involve nursing interventions that address these things. All the drugs the doctor orders and the fluids for any possible fluid deficit would be included under this diagnosis.

The next diagnosis I would include would be your

Risk for Fluid Volume Deficit R/T fluid loss from GI tract
- your goals for this are simply to maintain adequate fluid intake and output. Your interventions are to instruct the patient and his caregivers on kinds of fluids to give and how much to replace any fluid loss through vomiting and diarrhea that is still present and the importance of monitoring urine output

Beyond that, I don't see that any other nursing diagnoses are necessary. If you need three (I know some instructors like 3) I would add Knowledge Deficit. Teaching regarding how the patient contracted this infection, how to avoid further reinfection, follow up care, and teaching them about the signs and symptoms of this parasitic infection can be addressed.

A possible collaborator of care on this case scenario, and I think what your teacher was hinting at, would be the public or county (since this was on a farm) health department that would need to be notified of a contaminated water source that this patient got into. It's possible that this kind of parasitic infection has to be reported to the county/state health department by law. You need to research that. Your county or state public health department should have information on it's website regarding what kind of parasitic diseases must be reported. I would include this collaborative nursing intervention under the nursing diagnosis for Diarrhea:

Report patient's Cryptosporidium infection to the county health department as mandated by state/county law

I cannot stress enough that you should address positive aspects of behavior in a care plan. I would not use a diagnosis like Noncompliance unless I have proof that the patient is not going to do what the doctor is telling him to do (like, I actually heard the patient say, "I'm not doing that. Let's get out of here. This doctor doesn't know what he's talking about.") or there is a documented history of noncompliance in the medical record.

Daytonite, BSN, RN · Sep 5, 2007

P.S. Make sure you sequence your nursing diagnoses so your "Risk for" diagnoses are last. Actual problems always take priority over "Risk for" diagnoses.

midcom · Sep 5, 2007

I really appreciate your help and suggestions. It looks like I might be rewriting quite a bit of this project. I especially appreciated the advice about the noncompliance part. That word is really negative.

I believe that the reason the teacher wasn't so hard on me & approved of what I had so far was because this is an LPN program. We won't be writing care plans, at most helping the RN to do it. Sometimes I wonder why they stress it so much when most of us won't be going on to become RNs. I understand why it's important to understand them so I suppose the reason for the assignment but it seems kind of futile when they don't supply all the theory behind it, such as how to prioritize the diagnoses and why some are more important.

Anyway, I really do appreciate all your help.

Dixie

Daytonite, BSN, RN · Sep 5, 2007

i couldn't figure out why your teacher would approve your diagnoses, want you to include something about collaborative care (a concept that becomes very important when it comes to the difference between goals and outcomes) and tell you that your plans need to be time specific. i got the collaborative care hint right away with the medications and contaminated water. anything you are doing for a patient because it was ordered by the doctor is collaborative care, otherwise you couldn't legally, as a nurse, do those things. but specific goals come directly as a result of the nursing interventions performed because of the symptoms the patient is having.

when it comes to making goals it is important that they state a specific deadline by which they should be achieved. nursing goals predict 3 things about the patients symptom(s) or condition: (1) it will improve, (2) it will stabilize, or (3) it will support its deterioration. they should also give the predicted behavior you expect to see in the patient which is a direct result of the nursing interventions you are ordering--yes, ordering. let me give you an example of how this all flows logically for you.

nursing diagnosis

: diarrhea r/t infectious process due to cryptosporiosis aeb

abdominal pain and cramping, 10 liquid stools per day, and hyperactive bowel sounds

goal

: by noon tomorrow (time specific deadline), the patient will report no liquid stools (predicted behavior--improved symptom--that is a direct result of the nursing interventions listed below) for the previous 12 hours (time specific).

nursing interventions for this

:

(1) give antidiarrheal (name the drug) as ordered by the doctor (this is a collaborative intervention)

(2) advise patient and parents to observe the number and consistency of stools each day in order to determine the effectiveness of the medication (this is a collaborative intervention since it is something that would be reported to the md if the antidiarrheal wasn't working)

(3) encourage clear, lukewarm protein and electrolyte rich fluids until stools begin to be formed again (this is an independent nursing action. you can tell patients this without a doctor's order.)

(4) advise patient to avoid milk and foods high in fiber (this is an independent nursing action. you can tell patients this without a doctor's order.)

you would have other nursing interventions and might even have other goals. the above is just an illustration to show you how everything rationally flows from the assessed symptom (diarrhea) to the goals and then to the interventions. everything should fit together like a completed jigsaw puzzle.

i correspond with several lpn students that need to write care plans and many are given the basics of the nursing process just like rns are. the assessment skills taught may not be as intensive as an rn in a bachelor's program is taught, but the basic head to toe assessment as well as how that fits into the nursing process is often taught in lpn programs today. while lpns are not legally responsible in many states for writing care plans, many long term care facilities who hire lpns expect them to know how to write a simple care plan for a problem--even if they don't utilize nursing diagnoses. fyi. . .the use of nursing diagnoses is not mandated by any laws. they have just become commonly used by many facilities.

here are links to some student case studies that were posted on the internet by their instructor several years ago. it will give you an idea of how the students presented their case studies. there is a lot of variety in how they did them:

midcom · Sep 5, 2007

Thank you once more. I have printed out your suggestions & explanations. I'm glads I started this early as it looks like I'll be spending quite some time this weekend rewriting it.

This has really helped.

Dixie