NURSING CARE PLAN

vanilla bean · Aug 3, 2015

Hi reyshe! Welcome to allnurses! You may have more responses if you post in the Students section. There is a whole forum for Nursing Student Assistance. There are many helpful people here who regularly look through those boards to help students. I will caution you though, that people will request that you first share your thoughts on any topic or question before they share theirs. Most of the posters here who like to help students will prompt students to think about the problem and work through it using what they have already learned.

So... what are your initial thoughts on your case study? What nursing diagnosis are you considering and why?

reyshe · Aug 3, 2015

Hello vanilla bean,

Thank you for your response, i appreciate it. I will try to post this on that section. I hope they can help me with this. My nursing diagnosis for this is Impaired physical mobility r/t pain. As the patient verbalizes being uncomfortable and has restricted movement that makes him unable to perform ADL. Please correct me if I am wrong with my diagnosis. Thank you so much.

MendedHeart · Aug 3, 2015

How many do you need?

Do you have any other assessment data?

reyshe · Aug 3, 2015

Hello Mendedheart,

Unfortunately, i don't any other assessment data. We were instructed to make a care plan based on the scenario given. I only need one ND. Thank you so much for your response.

WCSU1987 · Aug 3, 2015

Doesn't give you much to go on ha. Do non medical psych care plan's at my work. I mean is Mr. Green a frequent flyer at your hospital. Where is the pain located. What type of pain. Does it radiate, Lumbago, any pain in the kidneys any pain anywhere else. On a scale 1-10. Medication on the 5 to 6 R's in regards to medication. Did he take his medication today? Does he seem alert does he know why he is on the medication for: Chest Pain, Diabetes, any red flags stand out. Is speech of dyspharsia, garbled, any weird smell from the mouth.

Battle wounds on the eye's how long has he been sleeping on average? How often does he sleep? Did he fall hit his head? Fluid coming out of the ears? Cold and clammy? Signs of priapism?

Any abnormalities with the vitals? Any other wounds? Swelling? Any other findings in head to toe assessment raise red flags?

I would document the assessment and present findings to the Doctor.

MendedHeart · Aug 3, 2015

Hello Mendedheart,
Unfortunately, i don't any other assessment data. We were instructed to make a care plan based on the scenario given. I only need one ND. Thank you so much for your response.

Well, not much information, these types of scenarios have been loathed around here because they are so exclusionary. That's not your fault though.

Do you have any resources such as NANDA?

The one you have works. Chronic pain is obvious. We were never allowed to use it in school.

Others could be possibilities :

Self care deficit

Altered sleep pattern

Ineffective coping

Been there,done that, ASN, RN · Aug 3, 2015

You could always use: Knowledge Deficit. This patient requires a lot of teaching.

That is, if that is still used. Been many moons since I wrote a care plan.

reyshe · Aug 4, 2015

Yes i have NANDA, my initial ND that I made for this scenario is Impaired Physical Mobility related to back pain.

I also thought, i would use Chorinic pain, because it is really obvius, but i will have difficulty with the related factor that causes the pain cause the data given in this scenario is limited. So what you think is the right ND for this scenario?

Thank younso much.

caffeinatedkat · Aug 8, 2015

Hi reyshe,

I'm hopeful you're successful in making your NCP because I was having a hard time as well. I need mine for my interview this September, are we on the same scenario?

Have a good day :)

nurseprnRN, BSN, RN · Aug 17, 2015

You are in school to learn to be a nursing diagnostician and treat people for what you diagnose. Yes, you are. You think it's all about learning how to do stuff like injections and IVs and tubes, but those are just tasks. You are learning how assess human responses and prescribe nursing measures.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

As an example: How does a physician make a medical diagnosis of anemia? The physician doesn't go to a list and say, "Gee, this guy looks pale, must be anemic, sounds pretty good to me," right? No- a diagnosis is made by obtaining a CBC. Then how does the physician know what caused it? Ah, then we collect more data-- renal failure (low erythropoietin), marrow malignancy (differential), occult GI beed (stool check), big bleeding with IV replacement (trauma record)... Then the physician can develop a medical plan of care to treat the causative (related-to) factors for the diagnosis made on data.

Nursing diagnosis is the same thing. A nurse can't just pick a diagnosis out of a list. And you can't make a diagnosis without data, either. So... my first suggestion is banishing the words "pick/find/choose" from any discussion of the NANDA-I list of approved nursing diagnoses. I think if students got this concept in their first week of school, that they will learn how to make nursing diagnoses, they'd have a better hook to hang their hat on, so to speak.

This is why you can't say, "My patient has diabetes. What are his nursing diagnoses?" Sure, when I admit somebody with diabetes I have some good ideas about possible nursing diagnoses based on my experience with caring for diabetics in many settings-- like, oh, knowledge deficit, fluid imbalance, impaired CV function, ineffective peripheral issue perfusion, pain, and many other things often seen in diabetics-- but I can't make one of them until I am sure the patient actually has defining characteristics. If I'm a smart person I will also keep my eyes and ears open for other nursing diagnoses for this patient -- maybe I see evidence of abuse, or sexual dysfunction, or death anxiety, or ineffective denial, or powerlessness, or risk for injury, or risk for self-directed violence, or contamination or .... You get the picture. This is why limiting your vision to "nursing diagnosis for diabetes" is so, well, limiting.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

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

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." You can thumb through your NANDA-I 2015-2017 and find lots and lots of medical diagnoses as related factors. They are not the origins of nursing diagnoses, however.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and a related/caustive factor. (Exception: see "risk for" diagnoses) (Think of the physician who has to have some lab work to diagnose anemia...same thing.)Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $39 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at students.

NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a nursing diagnosis first from a medical one and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

About Risk forâ€ diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed first, as safety ranks above all of the physiological needs in Maslow's hierarchy. What are nurses for if not to protect a patient's safety?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics the current edition.

"Risk for.. " diagnoses do not have defining characteristics, they have risk factors.

Third: Setting priorities. This sort of assignment is often made not only to see if somebody can recite rote information but to elicit your thought processes and see how well you can defend your reasoning. There is often no single priority; defend yours. Your faculty will be gratified to see you try and make your case.

So, what is the reasoning you have applied to your ranking, as applied to a specific patient or to people in general?

Now, as to your specific question:

It looks like you have looked in the NANDA-I and found a nursing diagnosis which meets the criteria above-- matches the assessment data you have and the related factors. You could also look at others, but as a beginning attempt, this is fine, because it has gotten you oriented to the reference you will use henceforward. Good work. :)

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Esme12, ASN, BSN, RN · Aug 18, 2015

Mr. Green is 56 year old man who has been admitted to your ward with chronic back pain. On examination, he is pale and looks exhausted. He has dark circles under his eyes and is constantly rubbing his lower back. When questioned, he tells you that he is unable to get comfortable and that his movement has become very restricted making him unable to perform many of his daily activities. When ask what he understands about his admission he says he hopes just to get some relief from the pain.
.

Grrrrrrrr I dislike it when instructors give such lame assessments.

First........Care plans are all about the patient and the patients problems. 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. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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

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.