Help with process paper

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Have a few questions regarding first process paper....could anyone give some input on 8 critical characteristics of CC as well as discharge planning needs for a pt CHF who came into ER SOB....thanks for your help and your time!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

What is a process paper? What does CC mean?

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process paper = nursing process paper. We did an assessment on a pt in clinical and have to come up with 5 nursing diagnoses for this patient. We also to come up with outcomes and interventions for our priority diagnosis (in this case i suppose it would have something to do with air exchange???) CC= chief complaint. Thanks for your interest!

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Welcome to allnurses! :balloons: I hope you'll find the site useful and interesting.

There are plenty of us here who are willing to help you understand and complete your school assignments, but please show us what work you have already done on the question/problem, and we will help you go from there.

We can help you with your schoolwork, but we're not willing to do it for you! :)

What have you already come up with on your own?

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8 critical characteristics for dyspnea1) location= lungs 2) quality/characteristics = (shallow, noisy respirations, but i believe this info should be subjective data...he denies pain, says he can't catch his breath 3) quanitity= seems SOB at all times but especially with increased activity (getting on bedside commode, talking) 4) setting= don't know what to put 5) associated factors= fatigue, weakness 6) aggravating/relieving factors= increased activity and talking aggravates, sitting in high-fowlers and resting quietly relieves 7) timing= at all times??? 8) pt. perception- he says he's weak as a kitten, can't get around to do what he needs to do

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Specializes in med/surg, telemetry, IV therapy, mgmt.

the nursing process is the problem solving method that is used specifically by nurses. the process, in general, however, is not owned by nursing exclusively. it is the way nursing goes about applying it that makes us call it the "nursing process". here is a real world analogy that will help explain why it is a problem solving method:

you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).

the 5 steps of the nursing process as they apply to care planning are as follows:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)

be clear, care planning is problem identification and problem solving. nursing diagnoses are identifications of the patient's problems (step #2 of the nursing process). to care plan the right way, it is best to follow the steps of the nursing process in the sequence they occur. that means starting with assessment. i described the different activities that are included with assessment above. doing them are going to help you find the 8 critical characteristics of the patient's chief complaint, although it makes more sense to me to identify the 8 critical characteristics of chf for this patient. those characteristics, or symptoms, are going to lead you right to the patient's nursing diagnoses. all nursing diagnoses have a list of symptoms (nanda calls them defining characteristics). you need to match your patient's symptoms with defining characteristics of a nursing diagnosis before you can choose it as your patient's problem. you cannot say this patient has an air exchange problem without doing a thorough assessment first and finding the abnormal data (supporting evidence, symptoms) that prove there is an air exchange problem.

start by looking through your physical assessment that you did of this patient (i assume this was a real patient that you took care of), what adls he/she was able to do, and looking up the signs and symptoms, pathophysiology and treatment of chf. then, make a revised list of this patient's abnormal data (symptoms). at that point you will begin to see patterns or groups of systems that belong with body functions (such as respiratory). that is when you start determining nursing diagnoses because you have defined characteristics (symptoms) to use in support of the diagnoses you choose. these defined characteristics are also what your outcomes and interventions are based upon.

priority is usually determined by maslow's hierarchy of needs with the need for oxygen at the top. the brain gets first priority for oxygen, then the heart, the lungs are next. this is the first tier of maslow:

  1. physiological needs (in the following order)
    • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]

    • the need for food and water

    • the need to eliminate and dispose of bodily wastes

    • the need to control body temperature

    • the need to move

    • the need for rest

    • the need for comfort

for more information on writing care plans see

https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing student discussion forum)

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