My First Care Plan -- Help!

CyclicalEvents · Feb 12, 2012

This person had a stroke. This person has heart failure. This person has COPD. Are these all one person? If so, he seems really sick.

Impaired swallowing r/t weakness of the swallowing muscles and diminished or absent swallowing reflex/gag reflex AEB severe aspirations on MBSS, dysphagia.

It's good to put a (secondary to [medical condition]) part when writing a nursing diagnosis, because it helps the reader understand what underlying medical condition is responsible for their current problem. Right now I am wondering why his swallowing muscles are weak and his gag reflex is absent. Did he have a stroke? A traumatic injury? Come out of surgery? Knowing this helps not only to prioritize this patient's care, it makes the nursing diagnosis clearer.

You should write impaired swallowing r/t blah blah secondary to medical condition AEB stuff

Impaired skin integrity r/t immobility, bed rest AEB disruption of epidermal tissue, pressure ulcers, saccral/heel wounds.

disruption of epidermal tissue is extremely vague and doesn't really mean anything, so I would remove that.

Decreased cardiac output r/t changes in myocardial contractility AEB occasional PVCs, sinus tachycardia, left axis deviation, anterior infarct.

Be more specific. "changes in myocardial contractility" doesn't tell me anything. Say decreased contractility or impaired contractility as that is what is going to lead to decreased output. Here you stated anterior infarction which sounds like the medical diagnosis, so you would actually say decreased CO r/t stuff secondary to anterior infarction AEB words.

Impaired urinary elimination r/t obstruction of enlarged prostate gland AEB urinary catheter, UTI symptoms.

The prostate gland is doing the obstructing, not the other way around.

MJ_14 · Feb 12, 2012

My pt is, indeed, very sick. The hospital that my clinical group got assigned to is a long-term acute care hospital with about 22 patients total who are all extremely sick with long lists of diseases/disorders. I saw him on Tuesday and two days later, Thursday, he was d/c to a SNF. That's how bad it is. Can you imagine your first clinical experience being as such? I'm thankful that I will come out of this with tons of experience and knowledge, but it is quite challenging! :)

As for the diagnoses, I actually used a care planning book and added my evidence. Thanks for your input! I am working on making these changes today and will hopefully be able to use your advice! Do you have a more specific suggestion for the "impaired urinary elimination" diagnosis? I'm wondering if I should just replace it with a totally different diagnosis.

Thanks again for your help, I was worried I wouldn't get any feedback!

nurseprnRN, BSN, RN · Feb 13, 2012

i think you did an absolutely awesome job for a beginner. i understand that some programs dont allow students to use a medical diagnosis in the cause of the nursing diagnosis (like saying "cva" or "botulism" instead of "weak swallow and absent gag reflex") even though nanda says it's perfectly appropriate sometimes, but it's also perfectly ok to use what you did for that one.

i don't mind your saying " disrupted epidermal tissue," but it's not really necessary because you have noted the presence of sacral (one c) and heel pressure ulcers.

i agree you should say the cardiac output is decreased, not just changed (sometimes people actually have increased co and it's an indication of bad things-- hard to believe, but true), and the catheter is the treatment for the bph, but hey, really good start.

my congratulations to your faculty if they've managed to get you to understand this much so early in your career.

MJ_14 · Feb 13, 2012

Thank you so much for your input! I still have trouble leaving out the obvious and finding what's really important so I'm working on that! As for the catheter evidence... we were told to list as much evidence as we could so I was sort of reaching for anything I could think of that may count as "evidence" of elimination problems. :idea: Making diagnoses seems so easy, but once I start writing it's actually more challenging than it appears. Hopefully I'm not totally off for my first care plan.

Esme12, ASN, BSN, RN · Feb 13, 2012

the first thing i need to do when i am helping anyone with their care plans is to go through the nursing process (which is what you should have been doing also). it helps organize you. i can't do step #1, the assessment because the patient and his medical records aren't in front of me, so i need to depend on the information that you've listed.

step #2 of the process is to make a list of all the abnormal data. these are the symptoms (nanda calls them defining characteristics) that the patient has. these are important because they form the entire foundation of your resulting care plan. they are the basis for any nursing diagnoses you choose, the goals you decide upon and the nursing interventions you will order. that's pretty much the entire nuts and bolts of the whole care plan, so these symptoms are pretty important and you need to give them their just due.

other information that is important to know is the patient's medical diagnoses. you need to know the pathophysiology of these conditions because it is through knowing the pathophysiology of the underlying medical conditions that you determine much of the r/t parts of your nursing diagnoses. one of the things you should be doing before even approaching the writing of this care plan is looking up all the information you can find about these five conditions: their signs and symptoms, how the doctors diagnose them, and what the doctors generally order to treat the signs and symptoms of them as well as their underlying cause. that is going to answer some if not all of the questions you posed in your post. you can download and print out the critical thinking flow sheet for nursing students which is a form attached to the end of every one of my posts to help you organize this information for each medical diagnosis. this learning of information about medical diagnoses is crucial to your critical thinking and problem solving of patients problems.

the next part of step #2 is to take the list of your patient's symptoms and shop for nursing diagnoses. a diagnosis is the resulting decision or opinion you make after going through the process of examination or investigation of the facts. you did your examination and investigation of the facts in step #1 (assessment). when a doctor diagnoses someone with a medical condition, they do exactly the same thing. they do a review of systems (medical history) and physical examination of the patient and consider all the abnormal data before putting a medical diagnosis on them. we nurses need to be as careful about doing this as well. we have the nanda taxonomy (a big word meaning a classification--an arrangement or ordering of the nursing diagnoses into some kind of logical grouping) to help us out.

so, you really need some kind of nursing diagnosis book as a reference to help you out here. i, personally, use nanda-i nursing diagnoses: definitions & classification 2007-2008 which is a small pocket book size and contains all the current 188 nursing diagnoses, their definition, the defining characteristics (symptoms) for each diagnosis, and the related factors (r/t's) for each diagnosis. most fit on one or two pages. this is the same information that is included in most of the currently printed care plan or nursing diagnosis books on the market. the authors pay nanda a fee to use this information. these authors, however, add other goodies to their books, like nursing interventions and goals which is really what most people buy these books for. most people overlook the nanda information. however, as students and new learners of how to diagnose, you really need to pay attention to it. before you assign any nursing diagnosis and related factors to a patient you need to verify that it is meeting the nanda criteria for that particular diagnosis. if it isn't, then you've diagnosed it incorrectly and need to keep looking for another more appropriate nursing diagnosis.

the way nanda skirts around this issue of intruding into doctor's territory is to look at the patient's reaction to his medical condition. this is an important concept that is prevalent throughout nursing diagnosing. we don't diagnose medical conditions, but the patient's reaction to them. that means you are assessing their symptoms. so, what are the patient's reaction to, or symptoms of, their diagnosis? this is where your foray into some online resources and filling out a critical thinking flow sheet for nursing students comes in very handy. now, assuming that you are probably new at assessment, i would compare that list i just posted with what you remember observing in your patient and think about if you might have noticed any of these things and just didn't write them down. if so, add them to your patient's list of symptoms now. you won't have a nursing diagnosis of infection, but you will use your patient's symptoms to diagnose them with other problems that are related to the symptoms of this infection. see?

lastly, diagnosis prioritization. prioritization is done by the patient's most important needs. keep in mind that the care plan is a problem solving process, so each nursing diagnosis is actually a patient problem. you list the problems in the order of which is most important of needing attention first. most instructors suggest prioritizing by maslow's hierarchy of needs. the hierarchy from most important to least important is as follows:

physiological needs (in the following order)
- the need for oxygen and to breathe
- the need for food and water
- the need to eliminate and dispose of bodily wastes
- the need to control body temperature
- the need to move
- the need for rest
- the need for comfort

[*]safety and security needs (in the following order)

safety from physiological threat
safety from psychological threat
protection
continuity
stability
lack of danger

[*]love and belonging needs

affiliation
affection
intimacy
support
reassurance

[*]self-esteem needs

sense of self-worth
self-respect
independence
dignity
privacy
self-reliance

[*]self-actualization

recognition and realization of potential
growth
health
autonomy

https://allnurses.com/nursing-student-assistance/nursing-diagnosis-help-276459.html

nursing resources - care plans

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

thanks daytonite.

Esme12, ASN, BSN, RN · Feb 14, 2012

https://allnurses.com/lpn-lvn-nursing/questions-about-writing-661965.html#post6052759

NCRNMDM, ASN, RN · Feb 14, 2012

Hey guys,
I am currently working on my first care plan for my recent clinical. I had to come up with 5 nursing diagnoses and have to put them in order from most important to least. Here's what I've come up with.. just need some suggestions on the order of importance. Any opinions are greatly appreciated. If you see errors in my actual diagnosis, please let me know! These are not in any particular order yet, by the way.
Impaired swallowing r/t weakness of the swallowing muscles and diminished or absent swallowing reflex/gag reflex AEB severe aspirations on MBSS, dysphagia.
Impaired skin integrity r/t immobility, bed rest AEB disruption of epidermal tissue, pressure ulcers, saccral/heel wounds.
Decreased cardiac output r/t changes in myocardial contractility AEB occasional PVCs, sinus tachycardia, left axis deviation, anterior infarct.
Ineffective airway clearance r/t increased production of bronchial secretions AEB wheezing, RR 22, yellowish to brown secretions.
Impaired urinary elimination r/t obstruction of enlarged prostate gland AEB urinary catheter, UTI symptoms.
What do y'all think? Terrible? :thankya:

I could be wrong in saying this, but I would have prioritized these differently. Here is how I would prioritize these, and I hope someone will correct me if I'm wrong:

Ineffective Airway Clearance
Decreased Cardiac Output
Impaired Swallowing
Impaired Skin Integrity
Impaired Urinary Elimination

In my program, we follow Maslow's Hierarchy of Needs, and we prioritize nursing diagnoses by that. Here is a basic breakdown of Maslow's (in case you don't use that at your program). I'm not typing the whole sheet, as it's rather long. I'm just summarizing.

Physiological Needs: Oxygen, Respiration, and Circulation
Nutrition: Food and Fluid and Electrolyte Balance
Elimination: Urine, Stool, and Skin
Comfort: Rest, Sleep, Hygiene, etc
Activity: Motor Function (Bone/Muscle)
Sensory Function: Sense Organs and LOC
Sexuality
Safety and Security: Peace of Mind, Protection, and Lack of Danger
Love/Feelings of Belonging: Interpersonal Relationships, Social (Family, Peers), Emotional (Nurses, etc), Giving and Receiving of Love or Friendship
Self-Esteem: Self-Reliance, Respect, Esteem, Confidence, and Trust
Reputation: Achievement, Leadership, Autonomy, and Leisure-Diversion
Self-Actualization: Learning, Realizing of One's Potential, and Ability to Adapt to Stress