Need help with care plan!!

Nonyvole, BSN, RN · Jul 4, 2014

So somebody with osteomylitis may end up with an amputation. You've decided to use Disturbed Body Image as your nursing diagnosis.

Related to: why does he have a disturbed body image? What is causing it?

As Evidenced By: What proof do you have?

Here's a diagnosis that I've used in the past. "Impaired gas exchange R/T pulmonary infection/pneumonia AEB decreased breath sounds, pt actively coughing, pt using supplemental oxygen." My diagnosis (impaired gas exchange), why I'm using it (patient had pneumonia), and my proof that I'm not a loon for thinking that way (patient was coughing. Breath sounds were decreased in some part of their lungs. They had to use supplemental oxygen to keep their O2 sats at a level that they didn't feel like they were gasping for air).

Esme12, ASN, BSN, RN · Jul 4, 2014

This....DRIVES ME NUTS! I think giving these type scenarios make it extremely for the new student starting out. What care plan resource do you have? GrnTea will come along and tell you this but you need the end all be all book of ND....Nursing Diagnoses: Definitions and Classification 2012-14cheap on amazon.

A care plan is ALL about PATIENT ASSESSMENT! If you don't have a patient these is no assessment. Grrrrrrrrrr

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.

So....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

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.

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.

Per GrnTea who says it best

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing 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) ________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma.

Each nursing diagnosis has specific criteria/definitions/taxonomy that the patient MUST fit into.

Esme12, ASN, BSN, RN · Jul 4, 2014

A nursing diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - This is the nursing diagnosis. a nursing diagnosis is actually a label. To clarify as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by NANDA, this is what is causing the problem and resulting in the symptoms. pathophysiologies need to be examined to find these etiologies. It is considered incorrect to list a medical diagnosis so a medical condition must be stated in generic physiological terms. You can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this. Etiologies, if they are other than of a medical source, are often the focus of outcomes and long term goals.
symptoms - also called defining characteristics by NANDA, these are the abnormal data items that are discovered during the patient assessment. They could be signs and symptoms of the medical disease the patient has, their responses to their disease, problems accomplishing their ADLS. They are evidence that prove the existence of the problem. If you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

Esme12, ASN, BSN, RN · Jul 4, 2014

My scenario is a 45 year old male hospitalized for osteomyelitis is newly diagnosed with bone sarcoma. He is married with 3 children and he and his wife are in the process of adopting another child. The patient coaches little league softball team at the local elementary school. Amputation has been discussed.

So you need to look up osteomylitis. You need to look up bone sarcoma. Think about emotional and financial as well as emotional issues that will affect this family. These patient have a TON of pain.

Now tell me what you think would apply to this patient. We will start there.

aly512 · Jul 4, 2014

We use Evolve for our concept map creator.. So far I have a

clinical manifestation as bone pain, tenderness, swelling and the nursing diagnosis for that is activity intolerance r/t immobility aeb verbal report of pain

The next diagnosis I have is Disturbed body image r/t possible amputation aeb patient states concerns and fears about change in body image

Do you think these would work?? Thanks for all the help already! This is our first care plan and just wish it was on an actual patient.. might make it a little easier!

AmyRN303, BSN, RN · Jul 4, 2014

Think in priorities. I hate these scenarios because the guy isn't sitting in front of you (the general "you") and you need to "see" this guy to put it together. So picture him in your head. Young guy, wife, three kids, active. He's just been told he has osteosarcoma. What do you know about that? He's been diagnosed with osteomyelitis (hint: it hurts...no, it HURTS) and now they're talking about doing an amputation.

Pain is a problem. And likely I'd say his biggest RIGHT NOW. He doesn't have a disturbed body image (at least not yet) but he has PAIN. My priority diagnosis would be acute pain. I don't have NANDA sitting in front of me right now, but I'd definitely start there. I'm not sure exactly what their preferred verbiage is right now but something like: acute pain r/t infectious process AEB patient statement of pain 11/10 on pain scale.

Visualize this guy, and get familiar with NANDA. Otherwise it's just slapping possible labels on a patient to make them fit the diagnosis, when they don't have it.

Esme12, ASN, BSN, RN · Jul 4, 2014

We use Evolve for our concept map creator.. So far I have a
clinical manifestation as bone pain, tenderness, swelling and the nursing diagnosis for that is activity intolerance r/t immobility aeb verbal report of pain
The next diagnosis I have is Disturbed body image r/t possible amputation aeb patient states concerns and fears about change in body image
Do you think these would work?? Thanks for all the help already! This is our first care plan and just wish it was on an actual patient.. might make it a little easier!

I see that you use evolve but what is your NANDA resource?

Personalize it just a little. How would you feel? These diagnosis cause severe pain. If this was you what would be your concerns? If this was your significant other....what would you think would be important to them?

45 year old male hospitalized for osteomyelitis is newly diagnosed with bone sarcoma. He is married with 3 children and he and his wife are in the process of adopting another child. The patient coaches little league softball team at the local elementary school. Amputation has been discussed.

Let me word it this way...I'm giving report.

The patient in 4902 is 45 year old male. He has been admitted for osteomylitis. He has been recently diagnosed with bone sarcoma. He is married with 3 kids and they are adopting another. He is in severe pain and an active guy....he coaches his kids. They are talking amputation on Tuesday.

What would be this patients concerns what is important for him?

nurseprnRN, BSN, RN · Jul 5, 2014

Aaarghh.

Esme is right, and here I am.

We hate faculty who encourage you guys to make up nursing diagnostic statements when it is both intellectually and professionally inappropriate. It's not your fault, but bear with me so I can explain how you must go about making nursing diagnoses.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts come first, diagnosis comes second, plan of care comes next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data. A physician will not be able to make a medical diagnosis of anemia without having a complete blood count. A nurse cannot make a nursing diagnosis without evidence either.

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. 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.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "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)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." Your patient probably has pain from his osteosarcoma (a biological cause).

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

It looks like you've pulled "disturbed body image" off a list because it looks good to you, because if someone has to have an amputation his body will look different or something like that, so let's check that out. It's on p. 291 in your NANDA-I 2012-2014.

Disturbed body image Domain 6, perception/cognition; class 3: body image

Definition: Confusion in mental picture of one's physical self.

Does that sound like something your patient is experiencing?

Defining characteristics:

Well, on page 291 there are literally dozens of potential defining characteristics to help you make this diagnosis. I'm going to outline a couple of representative ones that I think might apply to your assumptions (or disqualify them). However, if they don't, you need to go and look it up before you can make this kind of diagnosis.

* behaviors of acknowledgment of one's body

* behaviors of avoidance of one's body

* behaviors of monitoring one's body

* nonverbal response to actual or perceived change in body (e.g., appearance, structure, function)

* reports feelings that reflect an alternate view of one's body (e.g., appearance, structure, function)

* reports perceptions that reflect an alternate view of one's body in appearance

Objective

* actual change in function or structure

* changing ability to estimate spatial relationship of body to environment

* change in social involvement

* extension of body boundary to incorporate environmental objects

* intentional hiding the body part, intentional overexposure of body part

* missing body part

* not looking at or touching body part

* trauma to nonfunctioning part

* unintentional hiding or overexposing of body part

Subjective

* depersonalization of loss or part by use of impersonal pronouns

* focus on past appearance, function, or strength

* preoccupation with change, loss

* refusal to verify actual change

* reports fear of reaction by others

* reports of negative feelings about body (e.g., feelings of helplessness, hopelessness, powerlessness)

(there are more in these 2 sections)

Related factors

* biophysical, cognitive, cultural, developmental changes, illness, injury, perceptual, psychosocial, spiritual, surgery, trauma, treatment regimen

Now, can you make a diagnostic statement as outlined above for this nursing diagnosis using at least one of the required defining characteristics from the list plus a required related factor from the list? If you have assessment data to do so, then you made a nursing diagnosis :anpom:. If not, go back and try again with something else. It is literally not possible for nursing student to "make up a three-part nursing diagnostic statement" because, as discussed here, only NANDA-I can do that. You can use it all you want, and actually, you should use it, all the time. But you're no position to make them up. And your faculty should know that.

Now I understand completely that you don't have a lot of data here. And I also understand your faculty's instruction to "be creative." Well, in that case, I think the best thing you could do is to get the book and thumb through it.

Look at some of the headings as listed above. Do you think some of those might apply to somebody in this unfortunate man's situation? Look in every section-- don't just take the low-hanging fruit of pain. Check under stress/coping, life principles, role, sexual function, activity and rest, health promotion. All of these will have things to teach you about how to look at this patient and plan his care to give yourself or delegate.

Take a look at them. See what kind of defining characteristics might exist that you might find on assessment (because you're actually making this all up, right?). Then you're in a good position to fulfill your assignment without violating all the rules of making nursing diagnoses. As a bonus, you will be ahead of your classmates in being familiar with this excellent resource.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2012-2014 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

slk24299 · Jul 7, 2014

Hello, I am a 1st year nursing student that recently completed my 1st semester!!! In my 1st semester we had a class designated to prepare for the many nursing diagnoses ahead of us. I have to say that if you take the advice provided above by GrnTea and Esme12 you will be just fine. I personally found that when I utilized Maslow's hierarchy to consider what diagnoses was most important, it help to narrow the field of focus. The only other advice I would offer is to make sure you include a specified time frame that you wish to see your actions accomplished, even if it is ongoing upon release.

I know it's not much, but in combination with the advice above I hope it helps.

I will also be saving the above advice for my own reference next semester;)!!!