Need answers regarding care plans.

KrCmommy522, BSN, RN · Mar 22, 2018

First, NEVER be embarrassed to ask a question. You are SMART because you realize where you need help and you aren't afraid to ask for it!!

I think another member, Esme12, explains nursing diagnoses best:

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. 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 from our Daytonite
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 careplan 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.[/Quote]
Another member GrnTea (who I think is now nurseprnRN) say this best......
A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

Resources that will answer your questions:
https://allnurses.com/nursing-study-tips/student-resources-nursing-424826.html

https://allnurses.com/general-nursing-discussion/what-is-nsg-668863.html

https://allnurses.com/nursing-student-assistance/care-plan-help-907167.html

https://allnurses.com/nursing-student-assistance/nursing-diagnosis-help-952444.html

https://allnurses.com/general-nursing-student/nursing-diagnosis-help-983829.html

As for your questions:
1) Does a patient receive a care plan for every diagnosis?
It is not necessarily for the pts diagnosis. You are making a care plan, based on what you, as a nurse, can do for the pt. You don't say, "Okay, this is the pts medical diagnosis, so now I need a nursing diagnosis." That's not how it works. You don't look at the pts medical diagnosis, and then try to fit a nursing diagnosis to that medical diagnosis. Do not try to fit your patient to whatever diagnosis you have in your mind. You need to assess, collect your data, THEN find a diagnosis. As Esme12 says, "The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. The nursing diagnosis is what you are going to do about it, what are you going to look for, and what do you need to do/look for first.

2) What's the best way to choose a diagnosis? When I peeked in my Nurse's Pocket Guide, I felt like I could have chosen many of the diagnoses. How many can I put down?
You don't "pick" or "choose" a nursing diagnosis. A nursing diagnosis is MADE based on your evaluation of the evidence, your assessment, your data, etc.

nurseprnRN (I think formerly GrnTea) says it best:
There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. You can't come in and say, "My patient had a mitral (note spelling) valve replacement and I need a nursing diagnosis." Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.
Assigning a nursing diagnosis based on a medical diagnosis skips several steps essential to optimal and safe patient care. a medical diagnosis is only one piece of the puzzle; it does not by itself, provide the depth of information necessary to make an accurate nursing diagnosis.

3) Are the related to, AEB, planning, and outcome info only able to be taken from a care plan book with NANDA-I diagnoses or are nurses able to individualize them or make them up?
You take the related to and AEB from a care plan book with NANDA-I diagnoses. You do not make them up. All nursing diagnoses have (MUST HAVE) defining characteristics and related/causative factors as defined by NANDA-I. (Exception: "Risk for.." diagnoses have risk factors.) This is nonnegotiable. You can't just make them up.
As far as planning and outcomes, I do believe you can individualize them. When I was in school, I had a care plan book that was my favorite and then I had a couple others I used. They seemed to have different outcomes and plans. I always individualized them to what worked for my patient.

4) I understand that all care plan formats may be different depending on the facility, but I keep seeing ones with columns. Can anyone give insight as to what your facility does?
As you said, every facility has different formats. Do you want insight into hospitals or schools? The way my school did it was the first 2 pages was pt info (pt initials, DOB, date of admission, medical diagnoses, labs, etc). We had to have that filled out before we started clinical. Then, the next few pages were related to our assessment, nursing diagnoses, and plan, and evaluation. Sometimes the format changed a little depending on where we were (peds, OB), but it stayed pretty much the same.