Need Help W/ 1st. Care Plan, Please Help!!!

Valerie Salva, BSN, RN · Mar 6, 2008

Do you have a care plan book? There will be lots of NDX for CVA in your book.

What effects is the CVA having on the pt?

Base your NDX on that.

Daytonite, BSN, RN · Mar 6, 2008

a care plan is nothing more than your written documentation of the nursing process. the nursing process is the problem solving process we nurses use to determine the patient's nursing problems and attempt to resolve them. you need to burn the steps of the nursing process into your mind because from now until the day you retire from nursing you will be using it:

assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)

you follow the sequence of these steps in the order that they occur. you can do this critical thinking in your mind or commit it to paper. for a care plan you are going to commit it to paper for your instructors to inspect to see if you are "thinking" this out correctly.

here's an analogy to real life that might make the nursing process seem a little more practical for you:

you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).

in reality, you have been doing this problem solving method in your own life, you just didn't call it "the nursing process" or have a lot of fancy rules to go with each step. welcome to nursing!

the first thing you need to do is assemble all the assessment data you collected on this patient. you should have done a physical assessment and read through their medical record (chart) and written down as much of the abnormal information you could find. there is a older thread on allnurses that gives you a guide as to what you should be looking for in the chart: https://allnurses.com/forums/2228927-post5.html. part of your assessment activity is to evaluate your patient's ability to perform adls (activities of daily living) which are: bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. if you failed to do that, go back and think about what you observed and try to reconstruct an assessment now. one last and important thing that you need to do is to look up information about stroke (cva) and hypertension. you want to find out what the signs and symptoms of these conditions are, any complications that can occur with them and how the doctors treat them. in particular, you want to find the pathophysiology of these two conditions. you may need that information in helping you to understand some of the symptoms the patient is displaying.

as you can see, step #1 (assessment) is a big step and there is a lot of work connected with it. it is very important because the remainder of the care plan (and any critical thinking decisions you make) are dependent on the information you have collected during your assessment activities. so, you cannot short cut this step. you want to have as much information as you can get your hands on.

in step #2 you are going to start sorting through all that assessment information. you are specifically targeting abnormal signs and symptoms or patient reactions to what is happening to them. you want to put them onto a list--a symptoms list. this list is going to be extremely important to the writing of the meat of your care plan. everything from here on will be based upon the symptoms you have on that list. so, it's important that you list as much abnormal data as you can.

now, the next biggie that happens in step #2 that gets everybody's panties in a twist is choosing nursing diagnoses. this doesn't have to happen. so, listen up. every nursing diagnosis, just like every medical diagnosis, has a list of signs and symptoms. where can you find these lists of signs and symptoms of the nursing diagnoses? in the nanda taxonomy. you can either purchase it from nanda for $25 (nanda-i nursing diagnoses: definitions & classification 2007-2008) or you can frequently find it spread out throughout many of the currently published care plan books that include nursing diagnosis information. nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig has the taxonomy published in it. these two websites have the taxonomy for a limited number of the most commonly used nursing diagnoses that you can access for free on the internet:

you choose a nursing diagnosis based upon its definition, which you should always read, and whether or not your patient has one or more of the symptoms for the diagnosis. nanda calls the symptoms defining characteristics, so you need to get used to seeing that term in the taxonomy. defining characteristics = (is the same as) symptoms. it may be a little slow going at first to find the right nursing diagnosis because there are 188 of them and you don't know them right now. i don't know them all and i work with many of them all the time. after a while of working with nursing diagnoses you get used to using some of the same ones and it gets easier to assign them. you'll see a group of symptoms and know that they are a particular nursing diagnosis right off the top of your head. but that comes with time and experience. for now, you need to use a reference of some sort. some symptoms will be obvious as being respiratory or circulatory in nature and it will be easier to find the right nursing diagnosis to match with them. the same goes for the self-care deficits. others may be a little harder to match. i will admit that there are times when i have gone through my copy of nanda-i nursing diagnoses: definitions & classification 2007-2008 page by page just looking at defining characteristics or the definitions of the diagnoses looking for just the right one to match a patient's signs and symptoms. it happens and that is part of the learning curve. no one knows everything.

if you are required to write a 3-part nursing diagnostic statement, it goes like this:

p - e - s

p

= problem

e

= etiology

s

= symptoms

or

problem - etiology(ies) - symptoms

these are, in nanda language

nursing diagnosis - related factor(s) - defining characteristic(s)

in a care plan they look like this:

problem [related to]etiology(ies)[as evidenced by]symptom(s)

or

nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)

the related factor is the underlying cause of the problem or the cause of the signs and symptoms that the patient is having. to help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. to help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". "by taking away this factor, will the symptoms go away?"

remember this important rule: you cannot list any medical diagnosis as a related factor. you have to state a medical condition in some other scientific terms. as an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". they essentially mean the same thing--the difference is in the phrasing of the words.

the defining characteristics are always the signs and symptoms that come from that list you created from your assessment activities. these will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to adl evaluations that were not normal.

now, you can move on to step #3, the part of your care plan that will take up the most room on the paper: goals and nursing interventions. we go back to that list of symptoms again. remember, for each nursing diagnosis you chose, the patient had at least one or more symptoms that supported your use of it. those symptoms are now front and center. your goals and nursing interventions need to target those specific symptoms. your goals (or outcomes) relate directly to these interventions. goals/outcomes are what you anticipate or predict is going to happen as a result of performing those interventions. so, you see, these things are very intimately related and form a very nice rational circle of thinking. you will do this for each of the nursing diagnoses you have.

just a note. . .sometimes you will have a symptom that you just cannot perform a nursing intervention for. it happens. we can't do everything. the difference between that flat tire analogy and a care plan is that with patients and care plans you generally have more than one problem going on at a time. this increases the complexity of the care planning which is why you really need to follow the step by step approach so you don't get confused or side-tracked. some patients are going to come to you with multiple problems and you have got to be able to keep it all organized.

hope that helps get you started. begin with going over your assessment information. . .

akcarmean, LPN · Mar 6, 2008

daytonight excellent post nothing more to add

Esther2007 · Mar 7, 2008

Ineffective perfusion r/t interruption of flow--arterial venous or what your relates to your patient. For CVA that is number diagnosis that my instructor last year wanted me to use. Like the above post stated, you have to go by your book. If you need anymore help, let me know.

Good luck.

manofcare · Mar 9, 2008

Daytonite, excellent post. I'm a fourth semester ADN student and you really helped me understand a lot of things about care plans I have been writting for four semesters. I think the mark of a great teacher is someone that can make difficult concepts easily understandable. Kudos. My hat is off to you!!