Nursing Diagnosis Help

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I'm completly at a loss. I can usually make my complete care plans when I have all my information in front of me. I'm a terrible abstract thinker so maybe yall can give me ideas and point me in the right direction. Here's the assignment given.

Develop a care plan for a patient recently diagnosed with colon cancer, receiving their first round of Avastin who develops thrombocytopenia.

And of course there are guidelines for the instructors care plans which makes me become lost.

- no medical diagnosis (diarrhea, constipation, etc)

- can't use pain

- no risk for or potential for Dx

I'm stuck. Ideas? I need 2 Dx and 2 goals for each. I also have to make up supporting data.

A classmate mentioned Decreased Cardiac Output, so I guess I'll think of something for that. But anyone have any other ideas?

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Specializes in OR, Nursing Professional Development.

There are a few things to keep in mind when making a nursing diagnosis, and one of the key things is that while the medical diagnosis may influence your assessment of the patient, nursing diagnoses are made based on a nursing assessment of the patient.

Esme is one of AN's posters who has posted a lot of really good information on nursing diagnoses and care plans. If you use the search bar at the upper right of the screen, you can enter Esme and "nursing diagnosis" or "care plan" and find a wealth of information to help you.

Honestly, your instructor is going about this the wrong way by expecting you to complete a care plan on a fictional patient based on medical diagnosis and procedures. However, you can only work with what you have. Good luck.

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I thought so too, but thanks! I definitely will look them up! I'm new to this forum so I don't know my way around it yet.

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So for creating my fictitious patient, his signs and symptoms are weakness, dizzy, hypotension, tachycardia, stomach pain, and GI bleed.

I know platelet count has to be lower than 150,000 but what number platelet count should I give my guy? Also, any other classic signs and symptoms I could add in?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Welcome to AN! The largest online nursing community!

I don't like it when teachers do this since care plans are all about the patients assessment.....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 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

Quote
  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 say this best......

Quote

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.
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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
StephAnnE93 said:
So for creating my fictitious patient, his signs and symptoms are weakness, dizzy, hypotension, tachycardia, stomach pain, and GI bleed.

I know platelet count has to be lower than 150,000 but what number platelet count should I give my guy? Also, any other classic signs and symptoms I could add in?

So....look up the signs and symptoms for colon cancer. Look up the chemo drug Avastin and look up thrombocytopenia

Now that is where you will get your assessment information to make your care plan.

What Care Plan resource are you using?

Your need to start your care plan....This is a male/female patient ?years old. Color is pale skin is cool and moist. Patient has history of.....colon cancer symptoms here....Patient diagnosed with colon cancer and Avastin started on (pretend date) On (another fictitious date) the patient c/o (thrombocytopenia signs and symptoms).......vitals are....look up data.

Now

Quote
creating my fictitious patient, his signs and symptoms are weakness, dizzy, hypotension, tachycardia, stomach pain, and GI bleed.

Tell me how these are signs AND SYMPTOMS.

The patient complains of weakness dizzy blah blah blah....but the symptoms would be hypotension, tachycardia, orthostatic hypotension. The patient c/o stomach pain and had three large cranberry/bloody stools.....see where I am going with this?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I am exhausted tell me what you think....I will check back tomorrow

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Fatigue r/t .... AEB .....

Diminished Protection r/t ..... AEB

Anxiety r/t ..... AEB .....

I use the Ackley book. The three above are just a few off the top of my head for this you could use.

:)

Sent from my iPhone using allnurses.

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Also- Impaired skin integrity related to ..... AEB. ?

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StephAnnE93 said:
I'm completly at a loss. I can usually make my complete care plans when I have all my information in front of me. I'm a terrible abstract thinker so maybe yall can give me ideas and point me in the right direction. Here's the assignment given.

Develop a care plan for a patient recently diagnosed with colon cancer, receiving their first round of Avastin who develops thrombocytopenia.

And of course there are guidelines for the instructors care plans which makes me become lost.

- no medical diagnosis (diarrhea, constipation, etc)

- can't use pain

- no risk for or potential for Dx

I'm stuck. Ideas? I need 2 Dx and 2 goals for each. I also have to make up supporting data.

A classmate mentioned Decreased Cardiac Output, so I guess I'll think of something for that. But anyone have any other ideas?

Sorry they keep coming to me...

You could also do:

Fluid volume deficit r/t ...... AEB....GI bleed?)

Impaired mobility r/t ......AEB.....

?

Sent from my iPhone using allnurses.

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Fear, Anxiety, decreased cardiac output, fatigue, activity intolerance, impaired comfort, those are some that popped into my head.

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I can make a care plan easily. But I have trouble making pretend (realistic) data. I turned in the care plan so hopefully my instructor doesn't tear me apart too bad lol

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