Nursing Diagnosis Care Plan - Psychosocial

To write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

What else do you know about this patient? Does he have any other comorbidities?

The biggest thing about a care plan is the assessment, of the patient. The second is knowledge about the disease process.

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 them as a recipe to caring for your patient. Your plan of care.

Care plans must be chosen from the "approved" script....NANDA.

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I think the biggest mistake students make is finding their diagnosis and trying to fit the patient into it.

You need to let what the patient says, does and feels (the assessment) dictate what you do next. You need a care plan book. I prefer Nursing Care Plans: Diagnoses, Interventions, and Outcomes.

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. There are currently 188 nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. What you need to do is 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.

5 Step Nursing Process

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.

A dear friend to allnurses, daytonite (RIP) always had the best advice....check out this link: Nursing Diagnosis

What Is A Care Plan?

A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. The nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. One of the main goals every nursing school wants its RNs to learn by graduation is how to use the nursing process to solve patient problems.

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. 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.

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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.

Care plan reality:

Is actually a shorthand label for the patient problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every Nanda nursing diagnosis has a definition).

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). What I would suggest you do is to work the nursing process from step #1.

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.

You need to know what alzheimer's is....what the symptoms are, what treatments are available...if any. Does this patient have any other comorbidities?

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He is unable to verbally communicate and is combative at times. He is also a retired colonel and at one time was very active in his church.

So your patient, from what you tell me has...

Impaired Verbal Communication

NANDA-I definition: decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols

Chronic Confusion

NANDA-I definition: An irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli, decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior

Impaired Memory

NANDA-I definition: inability to remember or recall bits of information or behavioral skills

Risk for Falls

NANDA-I definition: increased susceptibility to falling that may cause physical harm

Psychosocial Interventions

Learn more about psychosocial interventions by reading it at Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards.