My first nursing care plan!

Blue Cat · Dec 7, 2011

Do you use Maslow's Hierarchy of Needs in your program? We have to put all the pertinent data into a Maslow's format to formulate our priority nsg dx's. I don't like doing that because it seems like busy work to me, but I can see how it would be helpful at times.

As for your patient, I think I would focus on the priority dxs being those r/t the cardiac issues, kidney disease, and DM since those have so many implications.

Hope this helps.

Blue

NCRNMDM, ASN, RN · Dec 7, 2011

Alright...so I am sitting here, trying to write up my first care plan. I have my patient information in front of me:
Female, 90 y/o, admitted to skilled nursing facility for multiple rehab services (pt, ot), her family would prefer her to stay permanently d/t her confusion and inability to properly care for her self anymore.
She is on quite a few medications including ones for edema, diabetes, anxiety, HTN...
She has quite the list of Medical Dx, including:
Diabetes Mellitus (Type 2)
Vascular Dementia
Chronic Diastolic Heart Failure
A fib
Difficulty walking
muscle weakness
chest pain
anxiety
glaucoma
macular degeneration
HTN
Chronic kidney dz, stage V
Insomnia
COnstipation
Peripheral Edema
And the list goes on...I listed the most significant ones...
When it comes to nursing dx, we have to use the NANDA ones...
I need some guidance on what nursing dx I would choose based on her medical dx...
I want to use Risk for falls, because she has a hx of them along with a few within the last yr, but I can't use that as a priority can I?
I need to come up with 5 to prioritize and then fully develop the top 2...I just need some feedback to get started...Thanks!!

Focus in on her atrial fibrillation, kidney disease, diastolic heart failure, and DM. What are you worried about with atrial fibrillation? What's happening to the heart, and what complications can arise from this condition? What are you worried about with kidney disease? What kinds of issues are you looking at here? Ask yourself the same questions for diastolic heart failure and DM. I will give you a list of possible diagnoses to use, but you will have to figure out the how and why, and write your own related to and as evidenced by:

Excess Fluid Volume
Risk for Decreased Cardiac Tissue Perfusion
Impaired Gas Exchange
Decreased Cardiac Output
Activity Intolerance
Fear
Deficit Knowledge
Impaired Skin Integrity
Risk for Unsable Blood Glucose Level
Risk for Infection

This list just covers the diagnoses that are related to the major life-threatening conditions your patient has. This doesn't include the minor things like Risk for Trauma, Constipation, etc.

nurseprnRN, BSN, RN · Dec 7, 2011

one of the biggest problems nursing students make for themselves is thinking that they can make nursing diagnoses without doing an assessment, before they see the patient, just make nursing diagnoses based on medical diagnoses. they can't. no one can.

it might help you to think that a nursing plan of care is developed from the nursing diagnoses you come up with from your nursing assessment, in a parallel way to how the medical plan of care is developed from the medical diagnosis obtained from the medical work-up. but there is no list of medical diagnoses with a second column for associated nursing diagnoses. nursing develops nursing diagnoses from nursing assessments.

yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology. i'm pretty sure i will probably see a constellation of nursing diagnoses related to these effects, and i will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. i might find readiness to improve health status, or ineffective coping, or risk for falls, too. these are all things you often see in diabetics who come in with complications. they are all things that nursing treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. but i can't put them in any individual's plan for nursing care until *i* assess for the symptoms that indicate them, the defining characteristics of each. nursing diagnoses are made by nurses using the nursing process (which i know you don't have a good handle on yet but we're trying to help), not dependent on a medical diagnostic process. nursing diagnosis is in no way subservient to or inferior to medical diagnosis.

some data may overlap from the medical assessment. for example, the medical diagnosis of anemia is made by looking at blood work that tells the physician about a shortage of (usually) red blood cells. one associated nursing diagnosis might be fatigue, since deficient red cells mean there is less oxygen to deliver to the body. another might be activity intolerance, for the same reason. however, some people tolerate anemia pretty well and may not exhibit characteristics of either of these, so you can't just say, "hmmm, medical diagnosis = anemia, must include activity intolerance in my care plan," because, well, maybe not. the physician has done the medical assessment; you have to do a nursing assessment.

so... make your assessment first, then see what nursing diagnoses that makes clear.

as with the diabetes example above, it is perfectly acceptable to take a great list such as mattmrn has laid out for you and study it ahead of time, with particular attention to the defining characteristics (what in the medical diagnosis process would be called "symptoms" and "test results") so you can keep your eyes out for them when you meet and assess your patient. but you cannot write a patient's nursing care plan based on nursing diagnoses before you assess that patient.

Esme12, ASN, BSN, RN · Dec 7, 2011

quote rnwriter:

are you scratching your head or are you maybe even ready to tear your hair out over how to come up with care plans? here are some words of wisdom from our own beloved daytonite.

(rip)

care plan basics:

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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

.

how does a doctor diagnose? he/she does (hopefully) a thorough medical history and physical examination first. surprise! we do that too! it's part of step #1 of the nursing process. only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. each medical diagnosis has a defined list of symptoms that the patient's illness must match. another surprise! we do that too! we call it "critical thinking and it's part of step #2 of the nursing process. the nanda taxonomy lists the symptoms that go with each nursing diagnosis.

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:

assessment
(collect data from medical record, do a physical assessment of the patient, assess adl's, 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)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself

is

a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems. why? because as a working

rn

you will be using that method many times a day at work to resolve all kinds of issues and minor riddles that will present themselves. that is what you are going to be paid to do. most of the time you will do this critical thinking process in your head. for a care plan you have to commit your thinking process to paper. and in case you and any others reading this are wondering why in the blazes you are being forced to learn how to do these care plans, here's one very good and real world reason: because there is a federal law that

mandates

that every hospital that accepts medicare and medicaid payments for patients

must

include a written nursing care plan in every inpatient's chart whether the patient is a medicare/medicaid patient or not. if they don't, huge fines are assessed against the facility.

you, i and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids. let me give you a simple example:

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).

can you relate to that? that's about as simple as i can reduce the nursing process 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.

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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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.

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 (ex: activity intolerance) is actually a shorthand label for the

patient problem

.

the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition).

activity intolerance

(page 3,

nanda-i nursing diagnoses: definitions & classification 2007-2008

)

definition

:

insufficient physiological or psychological energy to endure or complete required or desired daily activities

(does this sound like your patient's problem?)

defining characteristics (symptoms):

abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness

related factors (etiology):

bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle

i've just listed above all the nanda information on the diagnosis of

activity intolerance

from the taxonomy. only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.

one more thing . . .

care plan reality:

nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. they are all linked together with each other to form a nice related circle of cause and effect.

you really shouldn't focus too much time on the nursing diagnoses. most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. the nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

end quote

some examples of care plans.....

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

blueyesue · Dec 10, 2011

Daytonite was a great person and a huge blessing. She continues to teach and inspire us. That is so wonderful.

Esme12, ASN, BSN, RN · Dec 10, 2011

Daytonite was a great person and a huge blessing. She continues to teach and inspire us. That is so wonderful.

I used to try to put it in my own words many times before and it just doesn't work....so I just use hers. She is missed......:redbeathe