NDX Help!

What semester are you? What care plan books do you have?

Care plans are like the recipe card to care for your patient. Your care plan should be based off of your assessment. Care plans are all about the patient and the patients problems. 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.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What

is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...

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

1) 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)

2) 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)

3) Planning (write measurable goals/outcomes and nursing interventions)

4) Implementation (initiate the care plan)

5) 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.

Now...tell me about your patient.

Hello everyone,

I am a student nurse and need some assistance with my nursing diagnoses. Before I tell you what I'd like to use, I want to give a little info about this particular patient. Without going into too much detail, his main issue is his c/o feeling weak and fatigued. He is independent and able to use the bathroom on his own when he needs to. He has no desire to ambulate, although his son and I were able to get him out of bed for a walk. He denies any dizziness, not hypotensive, he is not at risk for falls. He is NPO, on TPN and his skin is very dry. I would like to use risk for impaired skin integrity as my NDX, but I am not sure what to use as the "related to." I don't want to say "immobility" because he does get up to use the bathroom without any issues. I know that "r/t" is pathophys. Could I say risk for impaired skin integrity r/t lack of desire to ambulate? He ambulates, but just not enough to prevent any skin breakdowns, if that makes any sense. Plus the dryness of his skin because he is malnourished. I need help! My brain is going in all sorts of directions. I just need someone to steer me in the right direction.

SO....looking at the information you have given. You are falling into the same trap that most new students fall into. You are looking at a list of nursing diagnosis, finding a diagnosis is and think it "sounds good" for the instructor to be impressed. Then try to fit the patient into that diagnosis. Which is completely backwards. At risk diagnosis does not have related to as a par of the statement. If there is a related to....it is not longer an "At Risk" because they actually have symptoms.

What is your assessment? What are the vital signs? Why are they in the hospital? Care plans are all about the details.

Look at what little assessment you gave:

c/o feeling weak and fatigued

no desire to ambulate

he is not at risk for falls

NPO, on TPN and his skin is very dry

he is malnourished. How do you know this? What is his albumin?

Leads me to ask questions.

Are you sure the patient isn't a fall risk? He c/o feeling weak and fatigued.

How old is this patient? That alone can make him a fall risk.

Why is he NPO and on TPN?

Why does he have no desire to ambulate?

Is he in pain?

Is he depressed?

What other meds is he on?

What is he medical history?

Are they checking his glucose while on TPN?

This is just a start...tell me about your patient