7 months to graduation and I fail a nursing course d/t my careplans

Daytonite, BSN, RN · Oct 7, 2007

hi, lashawn04, and welcome to allnurses! :welcome:

i can't explain what it is your instructors are doing. but i do know about the nursing process and writing care plans. there are two threads on allnurses that address the issue of writing care plans:

https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)
https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)

perhaps if you could tell me what some of the specific criticisms are that you are being told on your care plans i might be able to help you out. i answer a lot of questions about care plans and nursing diagnoses on the student forums. there is also a thread that has information about critical thinking which is tied in to the care planning process: https://allnurses.com/forums/f50/looking-test-taking-stratagies-224581.html - looking for test taking strategies

lashawn04 · Oct 7, 2007

Thank you. The problem is that I really didn't get any direction. I received comments such as, "I need senior level work" or, "elaborate more". Even speaking to the teachers face to face didn't help. Now I have to admit that on the last care plan I made a huge mistake, which they stated showed that I did not know the nursing process. The first care plan for that week I had Impaired skin integrity ( I don't remember the R/T) the AEB was the two surgical procedures the patient had and I also don't remember the other two AEB. The last clinical instructer stated that she feels that I got an unsatisfactory from the other teacher because my interventions and rationales leaned more toward the infection diagnosis. Her exact words was, "I would write Infection secondary to inpaired skin integrity R/T the surgical procedures, abcess, and temperature off 100.4". Well, there is no nursing diagnosis for Infection, because that is a medical diagnosis, so I used Risk for Infection (although my patient had an infection) and everything else my teacher said. Well, I dinged on that one too because I listed a "slew of AEB" (her exact words), which is not appropriate for a Risk diagnosis. I believe that I was so frustrated over the whole ordeal that I really did not think of what the teacher was sayiing when she gave the advice. And since I am always told to write more, I just listed everything I could think of about the patient, to make the care plan satisfactory. What made me more furiious was that the other instructor said that the first care plan (Impaired Skin integrity) was fine. Sorry if this is too long.

Daytonite, BSN, RN · Oct 7, 2007

the first care plan for that week i had impaired skin integrity ( i don't remember the r/t) the aeb was the two surgical procedures the patient had and i also don't remember the other two aeb.

well, your aeb items must be the symptoms that the patient has. surgical procedures are not symptoms. the incisions resulting from the procedures and a description of them are symptoms.

the last clinical instructer stated that she feels that i got an unsatisfactory from the other teacher because my interventions and rationales leaned more toward the infection diagnosis. her exact words was, "i would write infection secondary to inpaired skin integrity r/t the surgical procedures, abcess, and temperature off 100.4". well, there is no nursing diagnosis for infection, because that is a medical diagnosis, so i used risk for infection (although my patient had an infection) and everything else my teacher said. well, i dinged on that one too because i listed a "slew of aeb" (her exact words), which is not appropriate for a risk diagnosis.

your instructor is correct. there is no nursing diagnosis for infection. when using "risk for" diagnoses you are talking about problems that don't even exist yet so there can be no symptoms! interventions for those diagnoses is to monitor, observe and prevent the development of those symptoms.

you need to get a better understanding of the nursing process and how it translates into problem solving and writing a care plan. read the information i posted on post #4 of this thread: https://allnurses.com/forums/f205/first-time-nursing-diagnosis-254012.html.

the steps of the nursing process that are most critical to writing a care plan are the first three:

assessment (collect data)
nursing diagnosis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
planning (write measurable goals/outcomes and nursing interventions)

every nursing diagnosis has:

a definition (helps you to differentiate it from other diagnoses that seem like they might be similar)
a set of defining characteristics (symptoms, inferences or logical conclusions, observable behaviors)
a list of related factors (etiologies that have already been worked out for you; they are antecedent, or must exist prior, to the nursing diagnosis and the symptoms. in a very slick way many of the related factors slide around medical reasons for what is going on without actually using a medical definition. important note: nanda is a highly evolved system of nursing language [terminology])
a list of risk factors replaces the defining characteristics and related factors for the "risk for" nursing diagnoses that may develop

as a student, when you are choosing nursing diagnoses for a patient you really need to be using some kind of nursing diagnosis reference to help you out. you need to make sure that your patient has symptoms that match the criteria that go with the nursing diagnosis you want to use. a doctor doesn't tell a patient that they have the flu until they have done an assessment and make a decision that the patient actually has some of the symptoms of the flu. in that same spirit, a nurse doesn't diagnose a patient as having impaired skin integrity without having done an assessment and determining that the patient has the symptoms of altered epidermis or dermis (the definition of this diagnosis). the nursing diagnostic statement (that xxx r/t xxx aeb thing) was designed to show that nursing students understood how the steps of the nursing process were used to choose the nursing diagnosis they are using. if you go to the post i referred you to above, i talk about the elements in a 3-part nursing diagnostic statement.

using risk for infection and then listing all the patients symptoms of their infection was the wrong approach. you will never have aeb items (symptoms) with anticipated problems--ever. what you do is list out the patient's symptoms of their infection and look for other nursing diagnoses that have those symptoms. hyperthermia (fever) is one that can be used. if the surgical wound was infected you can still use impaired skin integrity or delayed surgical recovery.

by just listing everything you could think of about the patient you were not really thinking about what you were doing. a care plan is a problem solving process. the patient's signs and symptoms which you determine from your assessment is the foundation of the care plan. the care plan is all about treating those signs and symptoms. your goals and interventions are aimed at those signs and symptoms. you choose a nursing diagnosis based upon those signs and symptoms. a nursing diagnosis is nothing more than a fancy label that nanda has already developed for us to use. the trick is to have a reference book to help determine the correct nursing diagnosis until you can start rattling off the top your head the symptoms (defining characteristics) of the various nursing diagnoses. the nursing diagnosis is only a small part of the care plan, but it hangs more students up than any single item about the care plan. the related factors are the underlying cause for why the signs and symptoms are occurring--that's all. when the cause is eliminated the signs and symptoms magically go away. until that happens, we treat the signs and symptoms in the unique way that nurses can treat them. doctors also treat some of the same signs and symptoms in the unique way that doctors can treat them. and that is the difference between medical practice and nursing practice.

lashawn04 · Oct 8, 2007

No!!! The instructor told me to use infection. I used Risk for instead. I do think that I need to review the nursing process though. I will definately check out the links you gave me. I really appreciate your timely response.

RN BSN 2009 · Oct 8, 2007

So... now here's the question, what nursing diagnosis do we use for patients that have infections

smk1, LPN · Oct 8, 2007

So... now here's the question, what nursing diagnosis do we use for patients that have infections

I don't have my book in front of me but probably something like, "Risk for injury related to (what ever some of the symptoms are) secondary to (whatever type of infection it is) as evidenced by (whatever evidence is supporting your diagnosis). I think there is a fever diagnosis that might work for some situations as well.

Daytonite, BSN, RN · Oct 8, 2007

No!!! The instructor told me to use infection. I used Risk for instead. I do think that I need to review the nursing process though. I will definately check out the links you gave me. I really appreciate your timely response.

Sorry if I got that wrong.

However, it just brings up the fact that you need to be verifying your use of any nursing diagnosis by checking it in reference book to make sure you have the correct symptoms and related factors before committing to using it on a patient. If those elements aren't there, then it's time to re-group and rethink your decision to use that diagnosis. The reference book is going to trump what an instructor is telling you in a conversation off the top of their head because it is printed in black and write and you can point to it to defend your decision to use it.

Daytonite, BSN, RN · Oct 8, 2007

so... now here's the question, what nursing diagnosis do we use for patients that have infections

you use a nursing diagnosis that is based upon the patient's symptoms. what are their symptoms? that is always the basis that underlies the choice of any nursing diagnoses you use. you have to stop thinking about infection and think about what the infection is causing in the patient. that is what your nursing concern is. has it affected the care of a wound? [inpaired skin integrity] has it gone systemic and is now affecting body systems/organs? [ineffective fluid volumn, ineffective tissue perfusion] is there evidence of local tissue involvement as in an infected peripheral iv site? [ineffective tissue perfusion, peripheral] does the patient have a fever? [hyperthermia] that is the only way you approach this.

all diagnosing, whether you are a nurse, doctor, plumber, or car mechanic starts with an examination of the subject, in our case, the patient. this is why one of the first subjects you cover in learning the nursing process is assessment. your initial assessment of the patient is crucial to this whole business of determining the patient's nursing diagnosis.

if you have a book of nursing diagnoses take some time when you have nothing else going on to thumb through the pages and really look at the different diagnoses that are there to become familiar with some of them, if only to see their names. there are currently 188 of them. you might be surprised at what you find there.

ohmeowzer RN, RN · Oct 8, 2007

i bought a pediatric care plan book on amazon and it helped me. all the answers were in the book. you may want to look on amazon for a pediatric care plan book. good luck in school.. tell me how your appeal works out.

NanniesNurse12/8 · Oct 9, 2007

First of all. I think it is so wrong that they are failing you for that. I feel that it is a teachers job to remediate a student when they are just not catching a concept. So I truly think in your case, your instructors dropped the ball, so to speak.

I feel for you when you say, different teachers have different ideas of acceptable careplans. My school had the same problem. We, my fellow students and I complained. All of the instructors got together and came up with a grading rubric. To be fair and equal to all students. And also so all of the instructors were on the same page.

In terms of a Nursing DX for infection. Our instructors have us use, Risk for Injury: Infection (you can specify) r/t surgery, immunosuppression... you get the point.

My suggestion to prove your self, find a case study somehwere. And write a kick butt careplan, complete with rationals, labs, what to do, and what to do teach, and collaborative interventions. Anyways, my heart goes out to you. I'll say a prayer, Good luck my friend!

lashawn04 · Oct 9, 2007

Here is the update, I went to the preliminary hearing today (basically following the steps before I file an appeal) and was told by these three instructors that on the first day of clinical they did give a careplan rubric to the 1st term senior students and the reason why they failed me was because I never did anything based on the rubric. Here's the problem about this statement: I WASN'T THERE FOR THE FIRST FOUR WEEKS!:angryfire The course coordintor scheduled all my community experiences in the first 4 weeks, I did not get to the clinical unit until the 5th week, and no one gave me a rubric. Did any of these teachers take me to the side and say, "I know you have had your community experiences so lets go over what is expected of you in this clinical"? No, why? Because one teacher thought that the other teacher did it, AND the rubrics were all gone, so they ASSUMED that the last one was given to me by SOMEONE. Man I was more angry when I left that meeting, I let all of those teachers have it, and our dean was very vocal in how disappointed she was that unorganization is the sole reason why I was failed in this course. Thinking more into this, when I was constantly bugging these teachers for help with these care plans, NONE of them even thought to pull out this so- called rubric? I never knew there was a rubric until this meeting. It would be an understatement to say that I am highly pissed. Now, I have to wait and see if the teachers are going to change their minds about failing me or if I have to actually file an appeal. Thanks for listening.