Nursing care plan HELP

[gmoore00]

Nursing school has been so awful...I need to do good on this care plan & final the tests are very challenging. I have a care plan but I'm unsure if I'm doing it right.

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Mrs. Garcia been seen in the ortho clinic for steadily worsening pain in right knee. The pain began four months ago when she fell and hyperextended the knee. She reports that's the pain is more intense with weight bearing activities including walking & standing. Because of this, she is limiting her physical activities. She also reports a recent onset of muscle spasms in the right leg, both with activity and rest. The pain and muscle spasms are disrupting her sleep and making it difficult for her to enjoy daily activities. At home she is testing discomfort with acetaminophen and stretching exercises but no relief.

On physical exam, you notice a marked limp with walking, decreased extension in right knee, and a reluctance to allow her knee to be touched or manipulated. The knee is slightly swollen and warm to touch. During X-ray she grimaces in pain when placed in kneeling position. Her dpmedical diagnosis is Patellar Tendonitis, and she is started on regimen of NSAID. She is a widow and lives alone in her apartment.

i did the assessment of subjective and objective data

looked up her medical diagnoses and its background

I looked up several nursing diagnosis but I'm like lost on how to decide on which one

impaired comfort r/t a cure pain aeb pain states pain is more intense with weight bearing activities.

or impaired physical mobility r/t pain

or do I use pain as the diagnosis Acute Pain r/t fall aeb patient states pain as worsen.

[JustBeachyNurse, LPN]

gmoore00 said:

Nursing school has been so awful...I need to do good on this care plan & final the tests are very challenging. I have a care plan but I'm unsure if I'm doing it right.

---

Mrs. Garcia been seen in the ortho clinic for steadily worsening pain in right knee. The pain began four months ago when she fell and hyperextended the knee. She reports that's the pain is more intense with weight bearing activities including walking & standing. Because of this, she is limiting her physical activities. She also reports a recent onset of muscle spasms in the right leg, both with activity and rest. The pain and muscle spasms are disrupting her sleep and making it difficult for her to enjoy daily activities. At home she is testing discomfort with acetaminophen and stretching exercises but no relief.

On physical exam, you notice a marked limp with walking, decreased extension in right knee, and a reluctance to allow her knee to be touched or manipulated. The knee is slightly swollen and warm to touch. During X-ray she grimaces in pain when placed in kneeling position. Her dpmedical diagnosis is Patellar Tendonitis, and she is started on regimen of NSAID. She is a widow and lives alone in her apartment.

i did the assessment of subjective and objective data

looked up her medical diagnoses and its background

I looked up several nursing diagnosis but I'm like lost on how to decide on which one

impaired comfort r/t a cure pain aeb pain states pain is more intense with weight bearing activities.

or impaired physical mobility r/t pain

or do I use pain as the diagnosis Acute Pain r/t fall aeb patient states pain as worsen.

Why not acute pain. The AEB/ r/t must come from the official NANDA list

[gmoore00]

Yeah I was confuse on how to choose between diagnosis

#1: Impaired Comfort r/t injury of tendon aeb client states pain from fall.

#2: Acute Pain r/t injury of tendon aeb clients report of symptoms ( the nanda book has acute pain and impaired comfort with the same related factors such client reports or demonstrates discomfort facial mask of pain, being uncomfortable, then it had related factors related to inflammation or tendon or injury of tendon which she has a medical diagnosis of Patellar tendonitis

# I also looked at impaired mobility ?

now how do I decide which to choose..this is where I'm kinda lost its my first care plan we just started all this

[JustBeachyNurse, LPN]

Using maslows acute pain (since from a recent injury) 2nd impaired mobility

[gmoore00]

So acute pain should be my nursing diagnosis

[JustBeachyNurse, LPN]

gmoore00 said:

Yeah I was confuse on how to choose between diagnosis

#1: Impaired Comfort r/t injury of tendon aeb client states pain from fall.

#2: Acute Pain r/t injury of tendon aeb clients report of symptoms ( the nanda book has acute pain and impaired comfort with the same related factors such client reports or demonstrates discomfort facial mask of pain, being uncomfortable, then it had related factors related to inflammation or tendon or injury of tendon which she has a medical diagnosis of Patellar tendonitis

# I also looked at impaired mobility ?

now how do I decide which to choose..this is where I'm kinda lost its my first care plan we just started all this

Which is more accurate by your assessment?

[Esme12, ASN, BSN, RN]

Lets start back at the beginning.....

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

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1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

1. 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.

Another member GrnTea say this best......

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A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.