My first scenario - Need to come up with a mini-care plan and diagnosis.

when you are care planning you are engaged in problem solving, so you need to use the nursing process which is your problem solving tool. follow its steps in sequence. a lot of preliminary work goes into step #1 (assessment) which is the data gathering and the foundation of everything else that will follow:

1. 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)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]how to write goal statements: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

  • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
    

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 1 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 - what do you know about cvas (strokes)? what are their signs and symptoms? part of assessment is knowing what the pathophysiology, signs and symptoms and medical treatment is. what signs and symptoms of the cva does she have? look at the other two previous problems she has (the fractured hip and the fainting spell 3 months ago). is the fainting spell possibly related to the cva? what are fainting spells and what might be the cause of them? she also has a pulse that is regularly irregular. hmmm. does that have significance? is it connected to the fainting? how is the previously fractured right hip potentially going to affect her rehabilitation from this stroke since she has been left with right sided hemiplegia?

• admitted to the hospital for acute cva
  
• history of fractured right hip
  
• fainting spell 3 months ago
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - all problems must have signs and symptoms. here they are. the scenario gave them to you. whatever is abnormal during your physical exam and questioning of the patient is abnormal data that becomes evidence of some problem.

• pulse is regularly irregular
  
• right sided hemiplegia
  
• speech is slurred
  
• has difficulty swallowing
  
• withdrawn
  
• responds slowly to questions but the staff can understand her requests
  
• dependent for adl's
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - the trick is figuring out what nursing diagnoses the data belong to. that is why you need a nursing diagnosis reference to help you out when you are first learning to diagnose. . .you are being asked to list a priority diagnosis. diagnoses are usually prioritized by maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). ineffective tissue perfusion would be a nice diagnosis to use except for one problem--i don't think you have enough evidence to use it. this patient was admitted to the hospital 2 weeks ago, so her difficulty swallowing, slurred speech and slow response to questions which are a defining characteristics of acute cerebral perfusion problems because of oxygen deprivation began 2 weeks ago. what you are seeing now are the permanent damage she is left with. to use ineffective tissue perfusion for your assignment you need to know the pathophysiology of the cva. was it a blood clot (interruption of blood flow) or a hemorrhage (impaired transport of oxygen)? we don't know and that ios a problem because we can't identify an etiology. i don't like the regularly irregular pulse. that tells me that there is a cardiac arrhythmia. one of the biggest causes of strokes is arrhythmias. cvas are also a cardiovascular event. fainting is also a symptom of anemia. i want to diagnose this lady with

• decreased cardiac output r/t altered heart rate aeb regularly irregular pulse of 82
  

but the next problem i see would be

• impaired swallowing r/t neuromuscular impairment aeb difficulty swallowing
  

why? because nutrition issues follow oxygen and circulation on maslow hierarchy. swallowing is necessary to eating.

it's annoying not to have subjective data to work with

for ineffective tissue perfusion, i'm not sure what i would put for a related factor.

for impaired physical mobility, i think the diagnostic statement could be "impaired physical mobility r/t neuromuscular impairment (right sided hemiplegia), aeb inability to perform gross/fine motor skills on right side".

i'm sorry, i meant to say "objective" data. however, the scenario gives you a lot of data. whether the data is objective or subjective it is still abnormal data and that is what is needed to supply evidence of problems.

i'm still trying to get my mind around the decreased cardiac output diagnosis. it's ok to use that, with just the irregular heart rate as evidence? wouldn't we have to know how the pulse is irregular, like what kind of rhythm it is?

i think i'll try putting together a care plan based on decreased cardiac output, but i need to understand why that diagnosis is ok.

• assess/monitor/evaluate/observe (to evaluate the patient's condition)
  
  
• care/perform/provide/assist (performing actual patient care)
  
  
• teach/educate/instruct/supervise (educating patient or caregiver)
  
  
• manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
  
  

• http://www.strokecenter.org/prof/ems/
  - stroke interactive tutorial
  
  
• http://www.merck.com/mmpe/sec16/ch211/ch211a.html
  - merck manual information on strokes
  
  
  
  
• http://www.nlm.nih.gov/medlineplus/tutorials/strokerehabilitation/pt059104.pdf
  - stroke rehabilitation
  
  

Well, dazzle her that you picked up on something you weren't quite sure of, but you are trying to figure out. In healthcare we don't ignore something because we don't understand it. Tell someone. Yes, you can use a nursing diagnosis even if the patient only has one of the defining characteristics. That is how nursing diagnosis is different from medical diagnosis. Our diagnosing is more flexible. Your instructors may come up with rules that you need more than one defining characteristic, but that is because you are in their world and playing for a grade. In the real world you only need one.

Did you take anatomy? Check your anatomy book and see what it has to say about the heart and the heartbeat.

I'm glad it all worked out. The bigger picture is that you realize that you must (1) look at your assessment data first and (2) determine what the problem is from the data that you are given. I'm always trying to find ways to explain that concept to students that makes common sense. I don't like to use the doctor analogy because we do use some of the same signs and symptoms and I don't want to confuse people with medical diagnoses. They are not the same as nursing diagnoses. Car mechanics and plumbers follow a similar process, but I don't understand their terminology or what they really do. However, a car mechanic can't get in and solve a car's problem until they look under the hood and do an assessment first. They don't, as a rule, write a formal care plan but the same kind of problem solving logic is going on in their profession as well. After some time and experience you can run this stuff through your brain in an instant. Writing it down takes a whole lot longer.

The next care plans will be a little easier. Carry on, nurse.