NCP rules of r/t

Esme12, ASN, BSN, RN · Mar 9, 2013

What is your homework? Nursing diagnosis? If so there is no diagnosis that is inflammation. Nursing diagnosis is all about the assessment and what the patient NEEDS. You see what they need first then decide what applies. What care plan book do you have? A good care plan book with the NANDA I taxotomy is of the utmost importance

******Care plans are all about the assessment.....of the patient. Tell me about your patient, What is your assessment? What do they NEED? What is their main complaint? What are their co-morbidities? How old is this patient? What is their base line? What meds are they on?

YOU MUST have a good care plan book with the NANDA diagnosis and it defining characteristics.

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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. 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.

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

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.

THese sheet may help you out.....daytonite made them (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

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.

Now....tell me about your patients assessment...what do they NEED right now.

Esme12, ASN, BSN, RN · Mar 9, 2013

Hi there, I'm a 2nd semester nursing student and am currently working on a NCP for homework and don't have much experience. I'm wondering if I can i relate 'inflammation' to a medical condition?
E.g. Inflammation r/t 'acute exacerbation of ulcerative colitis', aeb a moderately elevated WBC count and pyrexia.
Or do I have to relate inflammation to something other than a medical condition?
Thanks in advance for any help :0)
Deb

There isn't actually enough information for me to help you with this.....technically if I just use what you have provided

Inflammation r/t 'acute exacerbation of ulcerative colitis', aeb a moderately elevated WBC count and pyrexia.

according to NANDA I it is hyperthermia....NANDA-IDefinition: Body temperature elevated above normal range

Note: Elevated body temperature can be either fever or hyperthermia. Fever is a regulated rise in the core body temperature or variation in the temperature set-point, as part of the host defense (Henker & Carlson, 2007). Hyperthermia is an unregulated rise in body temperature which is seen with heat illness, neurological disorders, neuroleptic malignant syndrome, or malignant hyperthermia, often with the temperature above 104° F (40° C). Hyperthermia is not adaptive and should be treated as a medical emergency.

Defining Characteristics

Flushed skin; increase in body temperature above normal range; tachycardia; tachypnea; warm to touch; seizures in children

Related Factors (r/t)

Anesthesia; decreased perspiration; dehydration; exposure to hot environment; inappropriate clothing; increased metabolic rate; illness; medications; trauma; vigorous activity

So you patient has hyperthermia R/T inflammation/infection from ulcerative colitis AEB elevated WBC and temp of xyz

Do you see what I mean?

DebCruickshank · Mar 13, 2013

thanks very much for your help, I always get this back to front for some reason. I have fixed.

Pyrexia r/t inflammation/infection from ulcerative colitis, aeb a temperature elevated above normal range and a moderately elevated WBC count.

Esme12, ASN, BSN, RN · Mar 14, 2013

For a NANDA I diagnosis using the proper taxotomy is....

hyperthermia r/t inflammation/infection from ulcerative colitis, aeb a temperature elevated above normal range (pyrexia) and a moderately elevated WBC count.

Pyrexia is not a NANDA diagnosis.

eva123 · Mar 16, 2013

Here is a simple tip for nursing dx...presenting symptom or risk r/t causative factor (then you could put the phrase " secondary to insert med dx" AEB what is seen with the patient, what patient complains of, labs, etc. [important to remember that for a risk dx do not put AEB because they are not actually presenting with it, there is a potential)