Need help with first nursing care plan - (pain)

Esme12, ASN, BSN, RN · Oct 14, 2012

ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. 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.

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. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

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.

Esme12, ASN, BSN, RN · Oct 14, 2012

That being said....by your scenario What would your assessment of this patient be? What does this patient say?

Scenario:

Mr. Jason Jackson is an 80 y.o. male widower who was admitted into your medical-surgical unit this morning. He has been complaining of pain in his right lower quadrant of his abdomen. Mr. Jackson states to you, "I have a sharp pain in my side that doesn't seem to go away. When I walked up the stairs, it really hurt me." When you asked how he rated his pain on a scale of 0-10; he replied it "was a 9/10". You also notice that he has facial grimacing and he hunches over while he walks around the room. He also guards his right side with his hands. You note that his general appearance looks flushed in his face and chest. He is perspiring and he complains that he "feels cool." You auscultate his lungs and they were clear throughout bilaterally. You took his VS and they were: B/P 155/96; P-105; R-24; T-102.7F. He told you he doesn't normally run that high with his pulse, BP, and temperature. During his last void, he excreted 190 mls of concentrated urine. He stated he hadn't felt much like eating or drinking lately. Mr. Jackson admits to eating canned goods and frozen foods at home because he does not like to cook for himself. He tells you that he is worried about how many tests they will have to run because he does not have supplemental insurance with his Medicare plan. Mr. Jackson said he has two children, but they live far away. His daughter Gloria lives in Florida and his son Chuck lives in Washington D.C.

So.... from this scenario what would you think about this patient......

Is his pain chronic or ACUTE? With the fever what is the likely hood has has an infectious process occurring, pyleonephritis?, with the dehydration. But the pain is in his RIGHT lower abdomen and it hurts to bend his legs and to walk standing up. (Psoas sign Psoas sign Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with either the passive extension of the patient's right hip (patient lying on left side, with knee in flexion) or by the patient's active flexion of the right hip while supine. The pain elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and therefore also causes pain.) what disease process causes this phenomenon? What is located in the right lower quadrant of the abdomen? (appendex). He is febrile, diaphoretic, flushed. He has tachypena, tachycardia, hypertension and hyperthermia.

He has concentrated urine showing dehydration. he has poor nutrition and lives alone. He is fearful of the hospital as he has no insurance othere than medicare........he has no family support.....they live far away.

Which NANDA diagnosis(s) fit this patient? (nanda list as contributed by vickirn (assistant administrator)

nursing diagnoses 2012 - 2014.pdf‎

firefly101 · Oct 15, 2012

yeah i am way off. thanks Esme.

Esme12, ASN, BSN, RN · Oct 15, 2012

You're Welcome! :)

firefly101 · Oct 16, 2012

i couldn't get the pdf file to open

could i have some more input? i'm working on this with a group and this is what we have now...

(sorry if this is still far off. we are struggling, lol)

ASSESSMENT:

Behavior

states pain is "9/10" in lower right abdomen”(I/S)

facial grimace(I/S)

flushed face/chest (I/S)

perspiration(I/O)

states “feels cool”(I/S)

BP 155/96; P-105; R-24; T - 102.7 F (O,I)

says pulse, BP and temp are high (S,I)

190 mL urine excreted last void, concentrated (I/O)

diet consists of mostly canned and frozen foods (I/S)

states "hasn't felt like eating or drinking lately" (I/S)

states “worried about number of tests” due to insurance (I/S)

hunches while walking, guards right side (I/O)

clear lungs throughout bilaterally (A/O)

Focal

Stimulation of pain receptors

Contextual

age (80 y.o.)

gender (male)

poor diet (only canned, frozen food)

increased tempurature set point

pain in LRQ

Residual

worried about health problem

low pain tolerance

stress r/t lack of health insurance

loss: Children far away

loss: of wife

low pain tolerance

anxiety

NURSING DIAGNOSIS: (just need to pick 1)

Pain r/t self care deficit

CLIET/ PT GOALS: (long term & short term)

Pt. will report reduced pain by 10/16/12 AEB (ST)

Reporting pain as 3 or lower on a scale of 0-10
Moving without guarding side or hunched over
Walking easily up steps without reporting pain

[*]Pt. will report increased appetite by 10/16/12 AEB (ST)

Eating two full, healthy meals per day

[*]Pt. will have increased fluid intake of at least 200cc with each meal by 10/16/12 (ST)

[*]Pt. will have decreased BP by 12/5/12 (LT)

[*]PT. will have decreased temperature by 10/20/12 AEB (ST)

Temperature within normal adult range (96.8-98.6 F)

NURSING INTERVENTION

Nurse will assess pain of pt. on a scale of 0-10 every 8 hrs
Nurse will inquire to pain medications to relieve pain
Nurse will provide resources, such as a registered dietitian, to help him learn to cook for himself
Nurse will provide 3 meals per day and record amount eaten while in-patient
Nurse will provide at least 200 cc of fluid with each meal and record intake
Nurse will ascultate BP once a day while in-patient
Nurse will provide information to pt. to getting a BP cuff, or provide places that take BP
Nurse will train pt. to take BP
Nurse will educate pt. in BP, what it means and what their goal value is
Nurse will inquire to antihypertensives to lower BP

Esme12, ASN, BSN, RN · Oct 16, 2012

Here is the link to the page/thread the original document is on.....

https://allnurses.com/nursing-student-assistance/student-resources-nursing-424826-page2.html

What are you looking for.....do you have a care plan/nursing diagnosis book? what semester are you? What care plan book does your school require?

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.

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.

This patient doesn't have a low pain tolerance. LOOK at the ASSESSMENT you provided!!! This patient is SICK!!!!!! If you were able to see them in person you would be alarmed at the patients appearance.

This patient has a ruptured appendix and is septic. This patient needs to go to the OR for an emergent appendectomy. Highlighted for you are the key aspects for this patient. In picking your one diagnosis for this patient was you CI specific about which one it needed to be? or that you needed to find an important one?

Scenario:

Mr. Jason Jackson is an 80 y.o. male widower who was admitted into your medical-surgical unit this morning. He has been complaining of pain in his right lower quadrant of his abdomen. Mr. Jackson states to you, "I have a sharp pain in my side that doesn't seem to go away. When I walked up the stairs, it really hurt me." When you asked how he rated his pain on a scale of 0-10; he replied it "was a 9/10". You also notice that he has facial grimacing and he hunches over while he walks around the room. He also guards his right side with his hands. You note that his general appearance looks flushed in his face and chest. He is perspiring and he complains that he "feels cool." You auscultate his lungs and they were clear throughout bilaterally. You took his VS and they were: B/P 155/96; P-105; R-24; T-102.7F. He told you he doesn't normally run that high with his pulse, BP, and temperature. During his last void, he excreted 190 mls of concentrated urine. He stated he hadn't felt much like eating or drinking lately. Mr. Jackson admits to eating canned goods and frozen foods at home because he does not like to cook for himself. He tells you that he is worried about how many tests they will have to run because he does not have supplemental insurance with his Medicare plan. Mr. Jackson said he has two children, but they live far away. His daughter Gloria lives in Florida and his son Chuck lives in Washington D.C.

firefly101 · Oct 16, 2012

i am first semester. this is my very first care plan with a group. we are lost. we have only had one lesson on care plans and now it is an assignment.

we put low pain tolerance as residual (we can't prove it but if he is rated his pain a 9/10, maybe he rated it so high because he has low pain tolerance. its a hunch. probably not the case on why he rated it so high, but its possible. in our class we did the same thing for a similar pain scenario).

we can assume he has appendicitis/ some sort of infection but we can't prove that either because that is a medical diagnosis. so thats another reason why we are struggling. if he is so sick what can we do for this pt? we're not really sure, so we were tackling the pain issue.

gotta go to class, be back soon. i'll look over the link when i'm back. thank you.

Esme12, ASN, BSN, RN · Oct 16, 2012

Again......like I said earlier.......you must let the assessment of the patient guide your diagnosis. every symptom relates to a certain taxotomy (definition/characteristic) in the NANDA diagnosis. YOU MUST HAVE a care plan/nursing diagnosis book. Without one you will not be able to complete these assignments.

Scenario:

Mr. Jason Jackson is an 80 y.o. male widower who was admitted into your medical-surgical unit this morning. He has been complaining of pain in his right lower quadrant of his abdomen. (ACUTE PAIN) Mr. Jackson states to you, "I have aWhen you asked how he rated his pain on a scale of 0-10; he replied it "was a 9/10". You also notice that he has facial grimacing and he hunches over while he walks around the room. He also guards his right side with his hands. You note that his general appearance looks flushed in his face and chest. He is perspiring and he complains that he "feels cool." You auscultate his lungs and they were clear throughout bilaterally. You took his VS and they were: B/P 155/96; P-105; R-24; T-102.7F. He told you he doesn't normally run that high with his pulse, BP, and temperature. During his last void, he excreted 190 mls of concentrated urine. He stated he hadn't felt much like eating or drinking lately. Mr. Jackson admits to eating canned goods and frozen foods at home because he does not like to cook for himself. He tells you that he is worried about how many tests they will have to run because he does not have supplemental insurance with his Medicare plan. Mr. Jackson said he has two children, but they live far away. His daughter Gloria lives in Florida and his son Chuck lives in Washington D.C.

So from this scenario you can assume that .......

complaining of pain in his right lower quadrant of his abdomen. (ACUTE PAIN) pain on a scale of 0-10; he replied it "was a 9/10". You also notice that he has facial grimacing

sharp pain in my side that doesn't seem to go away. When I walked up the stairs, it really hurt me." he hunches over while he walks around the room. He also guards his right side with his hands......you can deduct from your nursing knowledge that the patient may have a specific disease process that require certain interventions.

appearance looks flushed in his face and chest. He is perspiring and he complains that he "feels cool." his VS and they were: B/P 155/96; P-105; R-24; T-102.7F. (Hyperthermia)(Risk for Infection)

he excreted 190 mls of concentrated urine. He stated he hadn't felt much like eating or drinking lately (Deficient Fluid volume)

hadn't felt much like eating or drinking lately. Mr. Jackson admits to eating canned goods and frozen foods at home because he does not like to cook for himself.(Self Neglect)(Imbalanced Nutrition: less than body requirements)

He tells you that he is worried about how many tests they will have to run because he does not have supplemental insurance (Deficient Knowledge [specify])with his Medicare plan. Mr. Jackson said he has two children, but they live far away. (Readiness for enhanced Relationship)

All of these nursing diagnosis's have been taken from Ackley: Nursing Diagnosis Handbook, 9th Edition ....just one NANDA/nursing diagnosis/care plan book.

Esme12, ASN, BSN, RN · Oct 16, 2012

[TABLE=class: cms_table_msonormaltable]

[TR]

[TD]nursing diagnoses 2012 – 2014[/TD]

[/TR]

[/TABLE]

[TABLE=class: cms_table_msonormaltable]

[TR]

[TD]domain 1 – health promotion[/TD]

[/TR]

[TR]

[TD][/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]deficient diversional activity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]sedentary lifestyle[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]deficient community health[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk-prone health behavior[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective health maintenance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced immunization status[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective protection[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective self-health management[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced self-health management[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective family therapeutic regimen management[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 2 – nutrition[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]insufficient breast milk[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective infant feeding pattern[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]imbalanced nutrition: less than body requirements[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]imbalanced nutrition: more than body requirements[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for imbalanced nutrition: more than body requirements[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced nutrition[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired swallowing[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for unstable blood glucose level[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]neonatal jaundice[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for neonatal jaundice[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for impaired liver function[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for electrolyte imbalance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced fluid balance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]deficient fluid volume[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]excess fluid volume[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for deficient fluid volume[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for imbalanced fluid volume[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 3 – elimination and exchange[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]functional urinary incontinence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]overflow urinary incontinence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]reflex urinary incontinence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]stress urinary incontinence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]urge urinary incontinence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for urge urinary incontinence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired urinary elimination[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced urinary elimination[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]urinary retention[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]constipation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]perceived constipation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for constipation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]diarrhea[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]dysfunctional gastrointestinal motility[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for dysfunctional gastrointestinal motility[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]bowel incontinence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired gas exchange[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 4 – activity/ rest[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]insomnia[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]sleep deprivation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced sleep[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]disturbed sleep pattern[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for disuse syndrome[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired bed mobility[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired physical mobility[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired wheelchair mobility[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired transfer ability[/TD]

[/TR]

[TR]

[TD=width: 609]impaired walking[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]disturbed energy field[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]fatigue [/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]wandering[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]activity intolerance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for activity intolerance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective breathing pattern[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]decreased cardiac output[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for ineffective gastrointestinal perfusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for ineffective renal perfusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired spontaneous ventilation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective peripheral tissue perfusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for decreased cardiac tissue perfusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for ineffective cerebral tissue perfusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for ineffective peripheral tissue perfusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]dysfunctional ventilatory weaning response[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired home maintenance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced self-care[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]bathing self-care deficit[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]dressing self-care deficit[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]feeding self-care deficit[/TD]

[/TR]

[TR]

[TD=width: 609]toileting self-care deficit[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]self-neglect[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 5 – perception/ cognition[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]unilateral neglect[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired environmental interpretation syndrome[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]acute confusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]chronic confusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for acute confusion[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective impulse control[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]deficient knowledge[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced knowledge[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired memory[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced communication[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired verbal communication[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 6 – self-perception[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]hopelessness[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for compromised human dignity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for loneliness[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]disturbed personal identity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for disturbed personal identity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced self-control[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]chronic low self-esteem[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for chronic low self-esteem[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for situational low self-esteem[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]situational low self-esteem[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]disturbed body image[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]stress overload[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for disorganized infant behavior[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]autonomic dysreflexia[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for autonomic dysreflexia[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]disorganized infant behavior[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced organized infant behavior[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]decreased intracranial adaptive capacity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 7 – role relationships[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective breastfeeding[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]interrupted breastfeeding[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced breastfeeding[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]caregiver role strain[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for caregiver role strain[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired parenting[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced parenting[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for impaired parenting[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for impaired attachment[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]dysfunctional family processes[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]interrupted family processes[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced family processes[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective relationship[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced relationship[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for ineffective relationship[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]parental role conflict[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective role performance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired social interaction[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 8 – sexuality[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]sexual dysfunction[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective sexuality pattern[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective childbearing process[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced childbearing process[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for ineffective childbearing process[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for disturbed maternal-fetal dyad[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 9 – coping/ stress tolerance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]post-trauma syndrome[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for post-trauma syndrome[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]rape-trauma syndrome[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]relocation stress syndrome[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for relocation stress syndrome[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective activity planning[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for ineffective activity planning[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]anxiety[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]compromised family coping[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]defensive coping[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]disabled family coping[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective coping[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective community coping[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced coping[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced family coping[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]death anxiety[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective denial[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]adult failure to thrive[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]fear[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]grieving[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]complicated grieving[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for complicated grieving[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced power[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]powerlessness[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for powerlessness[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired individual resilience[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced resilience[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for compromised resilience[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]chronic sorrow[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]stress overload[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for disorganized infant behavior[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]autonomic dysreflexia[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for autonomic dysreflexia[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]disorganized infant behavior[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced organized infant behavior[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]decreased intracranial adaptive capacity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 10 – life principles[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced hope[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced spiritual well-being[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced decision-making[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]decisional conflict[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]moral distress[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]noncompliance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired religiosity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced religiosity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for impaired religiosity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]spiritual distress[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for spiritual distress[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 11 – safety/ protection[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for infection[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective airway clearance[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for aspiration[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for bleeding[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired dentition[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for dry eye[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for falls[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for injury[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired oral mucous membrane[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for perioperative positioning injury[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for peripheral neurovascular dysfunction[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for shock[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired skin integrity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for impaired skin integrity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for sudden infant death syndrome[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for suffocation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]delayed surgical recovery[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for thermal injury[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired tissue integrity[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for trauma[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for vascular trauma[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for other-directed violence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for self-directed violence[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]self-mutilation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for self-mutilation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for suicide[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]contamination[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for contamination[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for poisoning[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for adverse reaction to iodinated contrast media[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for allergy response[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]latex allergy response[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for latex allergy response[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]risk for imbalanced body temperature[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]hyperthermia[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]hypothermia[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]ineffective thermoregulation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609]domain 12 – comfort[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired comfort[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced comfort[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]nausea[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]acute pain[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]chronic pain[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]impaired comfort[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]readiness for enhanced comfort[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent]social isolation[/TD]

[/TR]

[TR]

[TD=width: 609, bgcolor: transparent][/TD]

[/TR]

[/TABLE]

nanda nursing diagnosis home page Attached Files

Nursing Diagnoses 2012 - 2014.pdf‎ (35.7 KB, 3572 views)

Esme12, ASN, BSN, RN · Oct 16, 2012

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. If we choose the complaint of chest pain. Fro example........Why does the patient have pain? This patient has pain acute pain R/T severe RLQ abdominal pain AEB facial grimacing, guarding of right side, B/P 155/96; P-105; R-24, patient states complaints of pain "was a 9/10"

From Gulanick: Nursing Care Plans, 7th Edition and Ackley: Nursing Diagnosis Handbook, 9th Edition

So for example...pain.....

NANDA describes Acute Pain

NANDA-I

Definition

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain, 1979); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.

Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968; APS, 2008)

Defining Characteristics

Subjective

Pain is a subjective experience, and its presence cannot be proved or disproved. Self-report is the most reliable method of evaluating pain presence and intensity (APS, 2008). A client with cognitive ability who is able to speak or provide information about pain in other ways, such as pointing to numbers or words, should use a self-report pain tool (e.g., Numerical Rating Scale [NRS]) to identify the current pain level and establish a comfort-function goal (Pasero, 2009a; Puntillo et al, 2009).

Objective

Pain is a subjective experience, and objective measurement is impossible (APS, 2008; Breivik et al, 2008). If a client cannot provide a self-report, there is no pain intensity level (Pasero & McCaffery, 2005). Behavioral or physiological responses should never serve as the basis for pain management decisions if self-report is possible (Pasero & McCaffery, 2005; Herr et al, 2006; Erstad et al, 2009). However, observation of these responses may be helpful in recognition of pain presence for clients who are unable to provide a self-report (Herr et al, 2006; Bjoro & Herr, 2008). Observable pain responses may include loss of appetite and inability to deep breathe, ambulate, sleep, and perform ADLs; demonstrate pain-related behaviors such as guarding, self-protective behavior, and self-focusing; and distraction behavior ranging from crying to laughing, as well as muscle tension or rigidity (Puntillo et al, 2009). Acute pain may be associated with neurohumoral responses that can lead to increases in heart rate, blood pressure, and respiratory rate (Dunwoody et al, 2008; Polomano, Rathmell et al, 2008). However, physiological responses are not sensitive indicators of pain presence and intensity as they do not discriminate pain from other sources of distress, pathologic conditions, hemostatic changes, or medications (Herr et al, 2006). Behavioral or physiologic indicators may be used to confirm other findings; however, the absence of these indicators does not indicate the absence of pain.

Note: The defining characteristics are modified from the work of NANDA-I.

Related Factors (r/t)

Injury, agents (biological, chemical, physical, psychological), infection

NOC

Outcomes (Nursing Outcomes Classification)

Suggested NOC Outcomes

Comfort Level, Pain Control, Pain Level

Example NOC Outcome with Indicators

Pain Level as evidenced by the following indicators: Reported pain/Length of pain episodes/Moaning and crying/Facial expressions of pain (Rate the outcome and indicators of Pain Level: 1 = severe, 2 = substantial, 3 = moderate, 4 = mild, 5 = none ([see Section I].)

Client Outcomes

Client Will (Specify Time Frame):

Use a self-report pain tool to identify current pain level and establish a comfort-function goal
Report that pain management regimen achieves comfort-function goal without adverse effects
Describe nonpharmacological methods that can be used to help achieve comfort-function goal
Perform activities of recovery or ADLs easily
Describe how unrelieved pain will be managed
State ability to obtain sufficient amounts of rest and sleep
Notify member of the health care team promptly for pain level greater than the comfort-function goal, or occurrence of adverse effects

Now apply this to your patient.

Here is a great thread about care plans

https://allnurses.com/nursing-student-assistance/1st-post-5th-789124.html

https://allnurses.com/nursing-student-assistance/1st-post-5th-789124-page2.html

Some example of care plans.....

Nursing Care Plan | Nursing Crib

http://www.fresnostate.edu/nursingst...gcareplans.htm

http://www.pterrywave.com/nursing/ca...plans toc.aspx

http://www.snjourney.com/ClinicalInf.../CarePlanN.htm

http://www.delmarlearning.com/companions/content/0766822257/apps/appa.pdf

http://wps.prenhall.com/chet_perrin_...ent/index.html

mssjez · Oct 16, 2012

I am also in my first semester and we have begun going over Nursing Care Plans. Some things that make sense to me and may help with this and future care plans are: clustering your data, use your nursing care plan/NANDA book, focus on the patient assessment.

We cluster our data into each of the body systems (i.e.Neuro, Cardio, Respiratory, Integementary, etc.). This allows us to see the areas of highest priority and were our Nursing Diagnosis should be focused. Use your care plan/NANDA book. Our school uses the "Nurse's Pocket Guide" but you need to pull your Nursing Diagnosis directly from this book and make sure that the definition fits your patient. Once you pick the best nursing diagnosis for what you patient data says, you select a related to (r/t) factor that fits your patient as well. These related to factors must be from what is approved for that diagnosis (this is why you need a NANDA book). If you are required, you add your as evidenced by (aeb) information which come DIRECTLY from your patient (not verbatim from the book).

Using the patient data to pick your diagnosis, r/t, and aeb factors is key.

On a side note, our instructors say never to pick a self care deficit because there are usually higher priority diagnoses going on.

Good luck! I hope this helped a little!