My first care plan!

hmvassar, ASN, RN · Aug 27, 2017

Great start you are on the right track. From what I see you are not overthinking it. Focus on the problem. The patient is throwing up and can't keep anything down. Here's a few things I would think about.

For the nursing diagnosis, sure surgery is a good reason for her nausea, but what is really causing it? How many days postop is she, has her bowel woken up from surgery? Well if your guts not moving and your eating what's going to happen? Vomit. So that would be nausea r/t decreased peristalsis. Or is she nauseous from pain? Surgery IS painful and can induce vomiting. Did her pain bring on the vomiting? Hopefully you see where I'm going with this. It's better to look at the cause of the nausea. As for as evidenced by, you can list multiple things here! This is your data to support that she's actually nauseous. So it would be "AEB" patient reports nausea (x amount of times), patient reports inability to eat/drink, patient appears diaphoretic. What did the patient look like to you that showed you she was nauseous? This is key assessment data and fits in the as evidenced by section. You can also say that the patient reports pain and nausea in the as evidenced by.

Also what does the nurse need to do after she gives an anti-emetic? Ensure it worked! Make sure one of your interventions includes reassessment of medications within a time frame.

Another thing I would point out is that if you were nauseous would you want to eat all meals? No. That isn't realistic. Be more specific and realistic here. Maybe something along the lines of the patient will drink x amount and eat x amount by the end of the shift. At most the client will start taking in fluids by the time that you leave your shift.

I also want to point out that if you are at risk for imbalanced nutrition should you be exercising? No, not really. Especially if you can't keep food down. So I would revise this. How are you going to get the nauseous client at risk for imbalanced nutrition to increase their nutrition? Step 1 fix nausea, which you have addressed in your care plan, okay what next? Maybe the nurse can instruct the client to take small sips of liquids or bites of food. Try looking up a care plan for risk impaired nutrition and look at interventions used. This will help you connect some dots to see the bigger picture.

Great job! Hopefully this is helpful!

hmvassar, ASN, RN · Aug 27, 2017

Oh! I thought of something. So I had to come back. A good goal for a patient at risk for impaired nutrition is to maintain an ideal body weight during hospitalization. I'll leave it to you to figure out how the nurse will "measure this"!

Castiela · Aug 27, 2017

Your care plan feels more detailed than mine ever were in nursing school. I'd caution about setting time goals... Patients and their bodies work according to thEir own schedule. Unless your instructor has asked for specific times, which then you've got to go with it I guess.

Don't forget interventions such as limiting smells which may increase nausea and chewing gum to stimulate gi motility. Pain medications can also cause nausea. I've often had to give anti emetics with pain medications because the pt otherwise couldn't take them.

Another intervention may be an Ng insertion to low suction if she has an ileus and change her back to npo status. She will need IV fluids, and you'll need to keep an eye on her electrolytes

hmvassar, ASN, RN · Aug 27, 2017

Your care plan feels more detailed than mine ever were in nursing school. I'd caution about setting time goals... Patients and their bodies work according to thEir own schedule. Unless your instructor has asked for specific times, which then you've got to go with it I guess.
Don't forget interventions such as limiting smells which may increase nausea and chewing gum to stimulate gi motility. Pain medications can also cause nausea. I've often had to give anti emetics with pain medications because the pt otherwise couldn't take them.
Another intervention may be an Ng insertion to low suction if she has an ileus and change her back to npo status. She will need IV fluids, and you'll need to keep an eye on her electrolytes

I agree with you Castiela. I always found "SMART" goals were difficult because they often became unrealistic when I said the patient will xyz by this time. I soon learned that being more broad with my time wording was helpful and realistic. I soon changed the goals to: The patient will xyz by discharge/2nd day postop/1 week postop.

Great interventions too. This is why nursing takes a team! :)

I also forgot to add that the patient is more at risk for a fluid volume deficit with vomiting and postop status because fluid is leaving/has left the vascular space. So the nurse could find measures to prevent losses and provide fluids through parenteral means (IV), decrease anxiety to prevent hyperventilation (insensible water losses occur this way), etc. Fluid volume deficits can quickly lead to shock and renal failure so this is a huge priority for the vomiting patient, and monitoring those electrolytes too like Castiela said! :)

katknits · Aug 27, 2017

Thank you for the responses! I took all the advice and made adjustments to my care plan. The advice you all gave me helped to me refocus and really think about the possible causes of the symptoms and what those symptoms might put the patient at risk for. I feel confident about my care plan, and that's really saying something since this is only my second week of class! I know it only gets more complex though :)

Esme12, ASN, BSN, RN · Aug 29, 2017

Hi! What semester are you? What care plan resources are you using?

Care plans are all about the patient. 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.

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. 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. Priority starts with what will kill the patient first.

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:

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)

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)

Planning (write measurable goals/outcomes and nursing interventions)

Implementation (initiate the care plan)

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.