nursing care plan help

Editorial Team / Admin · Feb 18, 2017

Do you have a nursing care plan book? What does your assessment of the patient tell you? Remember, nursing diagnoses are made based on the nursing assessment of the patient, not the medical diagnosis. A care plan book should tell you what the NANDA approved nursing diagnoses are- and the book published by NANDA itself will be the most accurate and up to date.

cheath38 · Feb 18, 2017

Hi,

First of all, thanks for the response. I just joined this site, and I'm still learning how to communicate on here. I do have my NANDA book as my general guide for writing care plans, but I've never had a patient with acute renal complications. We profiled a patient last week to write an assessment on and do a two part care plan. The main medical diagnosis was community acquired pneumonia, and my first diagnosis is "Ineffective Breathing Pattern". Without breaking down her entire hospital stay and medical background, suffice to say, she developed renal issues as a result of vancomycin treatment. She was early sixties, normal weight, minor newly diagnosed hypertension, no other chronic health issues. But after days of IV antibiotics, which resulted in diarrhea, and several tests using contrast dye since admission..she is having the above listed renal issues. Specifically, her lab values were off/high and she was drinking tons of water and barely urinating. She did not have edema. My instructor agreed after seeing her high vanco trough reading that she was indeed having renal issues, but when I listed several "urinary" nandas, we both agreed they didn't quite fit. I have limited experience with nandas, and because the findings are so new, I am hesitant to list "acute renal failure" and the accompany nanda for that. Any guidance here??

Editorial Team / Admin · Feb 18, 2017

Guidance: forget about the medical diagnosis. Seriously. Nursing diagnosis isn't based on it. It's based on your patient's nursing assessment. You can have a patient admitted for pneumonia and subsequent renal failure- but that isn't looking at the patient as a whole, which is what nursing does.

Let's just look at the diarrhea for an example- what can diarrhea cause in a patient? What about skin breakdown? Mobility issues and an urge to get to the restroom in time? If the patient is bed bound, what can that lead to?

What about the emotional side of now being in the hospital for a longer time? What's going on at home- are there pets or a spouse or grandchildren that the patient was the primary caregiver for? What kind of stress could the patient be going through because now she isn't at home to do that?

By looking at the patient as a whole and not focusing on just one little medical diagnosis, we've now opened up a whole world of possible nursing diagnoses that are not based on the medical diagnosis.

cheath38 · Feb 18, 2017

Thank you for the suggestions. I know it may appear like I'm trying to make my patient "fit" a certain diagnosis, I have carefully collected data regarding all levels of functioning, and all body systems. It was just that when writing the care plan, the main turn of events and second most critical body systems that had acute changes was renal. After analyzing all my data, labs values, patient symptoms (including large fluid input, thirst, dehydration, yet minimal, concentrated output) the possibly nephrotoxic treatment regime for pneumonia and copd, acid/base balance, and several other factors that "painted a picture" I have decided to use the NANDA Risk for Impaired Renal profusion. The reason I felt I needed a "NANDA" to help "guide" my interventions, is because my instructor looks for the goals/interventions to closely follow and strictly adhere to the information given under a specific diagnosis. The interventions (in real clinical/nursing practice) are in fact steps that would be taken, but of course, tailored to my patient. Its just hard when you have a picture of what is happening, and are "REQUIRED" to stay within parameters for a very specific nanda. I know everyone says to collect data (assessment) first, and I did that...but the suggestion to go into goals and interventions without establishing a set NANDA is contradictory the method of writing care plans that I was taught. I can use clinical reasoning and logic to make my own interventions/goals, but my instructor checks to see if they are EVIDENCE based SPECIFICALLY for a certain nanda. So, as I am pressed for time, it would be counter-intuitive and possibly a waste of time to form my whole detailed care plan, then try and attach a NANDA that fit my patient's goals/nursing interventions...or have to change all the steps I outlined. Does that make any sense? I agree, the rigidity of how the care plans are reviewed and graded, can make it feel like I am just trying to "make symptoms fit" a generic care plan (and that is the opposite of individualized, patient centered practice) But, I try to find a balance between "care plan expectations" and holistic care of my patients while I am a student.

AliNajaCat · Feb 18, 2017

There is no such thing as "a NANDA." Well, there is, but it's an organization that puts out the-- THE-- definitive book with approved and validated nursing diagnoses, current edition 2015-2017. Get this. Your other care plan handbook, whatever it is, is not current (I know, my name is probably in one of the ones you have as a contributor, and it takes 2-3 years to bring one to press).

You are not hearing the PP who said, "Forget medical diagnoses." She's right. Really. Why is that?

Yes, absolutely you have to understand the medical diagnoses and pathophysiology for your patients. However, you are not responsible for the medical diagnostic process that gave them to you. Learning to think like a nurse is not a watered-down second-best thing. You are in nursing school to learn to think like a nurse, and that means learning to make nursing diagnoses so you can develop a nursing plan of care to deliver/delegate. That complements the medical plan of care-- and the physical therapy plan of care, and the nutritionist plan of care, and all the others that affect your patient.

Yes, nursing does help implement parts of the medical plan of care (but not all-- think therapy, labs, dietary, social work, radiology, surgery...) But at least half of what you will do for a patient as a registered nurse will be nursing care, driven by nursing assessment, evaluated by nursing, autonomous, and accountable to nursing, not medicine. Think about that.

So. Look at your patient with new eyes. Figure out what your assessment indicates he needs of NURSING care, not merely parts of the medical plan of care delivered by nursing. I know this is hard. If it were easy, nursing school would only take about fifteen minutes, LOL.

Unfortunately I am unable to refer back to your post to make further additions here. However, if you look at some of the other threads here about care planning, setting priorities, and the like, you will find a lot of advice on how to use NANDA-I to learn to think like a nurse by making a nursing diagnosis (not "choosing" or "picking" one).

You make a nursing diagnosis the same way a physician makes a medical one-- you assess, you get data, you compare your data with the defining characteristics for the possible diagnos(e)s you're considering, and when you find a match, you can make the diagnosis with confidence. Yes, you do. You are in school to learn how to make nursing diagnoses so you can make decisions about how to plan and deliver/delegate nursing care for them as an autonomous professional that the RN is. Think about that.