POC help for shaken baby

Daytonite, BSN, RN · Jan 16, 2010

care planning is merely determining a patient's nursing problems and developing strategies to do something about them. organizing the care plan by body systems is merely the way your instructors want you to approach the nursing problems. the nursing process which you should have already been exposed to and will be something you are expected to know and will be tested on when you take the nclex is a problem solving tool. you should be following it step by step to care plan. diagnosing is step #2. before we even get to determining what the nursing problems (nursing diagnoses are merely names by which we identify the nursing problems) a thorough assessment of the patient should have been done (step #1 of the nursing process). a good nursing assessment includes doing the following:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking

the abnormal data is pulled aside and becomes the basis for the nursing problems--in effect, it becomes the aeb (evidence) that proves the existence of each nursing problem. the related factors for your nursing diagnostic statements are often based upon the pathophysiology of the medical conditions that the patient has which is why it is important to review the pathophysiology, signs and symptoms and complications of their medical condition/disease.

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda. this is what is causing the problem. it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

you can see examples of care plan construction on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans