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Nursing Care Plan help!

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by afelice120 afelice120 (New) New

I have a pt with a hx TBI, hx seizures, and baseline AMS. He was admitted two days ago with increasing AMS secondary to a UTI. He has failed bedisde and video swallow studies, so has been NPO >24 hr until we can get a G-Tube in him. He has a PICC and a long term foley catheter, he's on contact isolation for a hx of ESBL, and is on bedrest due to a fall risk. The AMS has resolved to his baseline, so I'm having trouble coming up with nursing Dx. I need 10 nsg dx - 3 with interventions and assessments, and 7 with just a name of the dx and related to's/AEB's.

What I have so far:

- Imbalanced nutrition: less than body requirements r/t inadequate intake AEB required NPO status >24hr.

- Risk for infection: aspiration pneumonia r/t failed bedside and video swallow studies.

- Risk for injury r/t hx of seizures.

- Risk for infection: CLABSI r/t PICC line.

Can you guys think of any others?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Hi! Welcome to AN! The largest online nursing community!

What semester are you? What care plan resource do you use. Are you in a RN program? Does your program follow the NANDA guidelines? If they do the R/T isn't a part of the at risk diagnosis.

Care plans are all about your assessment of the patient. Not what the patient has but what the patient NEEDS.

Hi, I am a 4th semester student in an ADN program. We do use NANDA guidelines, and have been instructed that with Risk for dx, you must identify the r/t to specify the risk, but not the AEB as there is no evidence (being it is only a risk). I do understand how to develop a nursing dx, I am just really struggling with coming up with 10 of them for this particular patient since his chief complaints (AMS and UTI) are resolving.

NICUismylife, ADN, BSN, RN

Specializes in NICU, RNC.

Consider the complications that can result from bedrest. Are you permitted to utilize Nanda-approved RC (risk for complication) diagnoses? There are quite a few of those you could use. Worst case scenario, you could resort to psychsocial dx.

Yes, we are. I'll try that, thanks!

- Imbalanced nutrition: less than body requirements r/t inadequate intake AEB required NPO status >24hr.

- Risk for infection: aspiration pneumonia r/t failed bedside and video swallow studies.

- Risk for injury r/t hx of seizures.

- Risk for infection: CLABSI r/t PICC line.

Coupla things to help you MAKE (not "choose") nursing diagnoses.

1) Risk diagnoses do not have related (causative) factors, they have RISK factors. So since having a test isn't a risk factor, what is?

Also, I'm not seeing aspiration pneumonia as a risk factor for infection in my NANDA-I 2015-2017.

2) "Related to " means "caused by." Remember that.

3) If he aspirates AEB his studies (see how that works? evidence is data-- you know he aspirates because it was demonstrated by his swallow studies) then what is ASPIRATION a cause of?

3a) Or, look in your NANDA-I 2015-2017 to see if there's a "Risk for aspiration" nursing diagnosis. (Yep, there is...) Then see which of the risk factors listed allow you to make this diagnosis.

3b) Or if he already has aspiration pneumonia, he's not at risk for it any more, he has it. What do you observe about him about the effects of his pneumonia?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Coupla things to help you MAKE (not "choose") nursing diagnoses.

1) Risk diagnoses do not have related (causative) factors, they have RISK factors. So since having a test isn't a risk factor, what is?

Also, I'm not seeing aspiration pneumonia as a risk factor for infection in my NANDA-I 2015-2017.

2) "Related to " means "caused by." Remember that.

3) If he aspirates AEB his studies (see how that works? evidence is data-- you know he aspirates because it was demonstrated by his swallow studies) then what is ASPIRATION a cause of?

3a) Or, look in your NANDA-I 2015-2017 to see if there's a "Risk for aspiration" nursing diagnosis. (Yep, there is...) Then see which of the risk factors listed allow you to make this diagnosis.

3b) Or if he already has aspiration pneumonia, he's not at risk for it any more, he has it. What do you observe about him about the effects of his pneumonia?

I have found it interesting that most of the nursing schools do not require the NANDA book. The use other "care plan books" I have also heard of schools refuse to let the students use any "Non approved" books including NANDA.

Drives me nuts.

Having taught in schools and contributed to textbooks (the latest being a very heavily-used "nursing diagnosis handbook") and serving on the NANDA-I research and education committee as we speak, I think there are a lot of things going on here.

First, many faculty learned about NANDA back in the day before it was NANDA-I when it was a pain in the neck, totally academic-speak, very dogmatic, and not the least bit user-friendly. And some of it downright silly. So they think it's still like that and don't prescribe it for their students. This is an awful error, as the last 2 editions (2012-14 and 2015-17) have a WONDERFUL intro section aimed specifically at students that give them a really good jumpstart into thinking like a nurse. Hell, I've been using it for at least 6 years and I'm still learning how great it is in my current work, and I really do use it because it gives me power when I have to justify my nursing judgment.

Second, many colleges have contracts with publishers for their books, and that's all they buy. The NANDA-I is cheap and easily used in hard copy or on your e-reader/Kindle/iPad, and so I tell students to get it themselves at Amazon and get ahead without telling their faculty why. Extra learning ought never to be forbidden or avoided!