1st care plan

NoviceRN10 · Feb 22, 2008

Don't you have a nursing diagnosis textbook? We use Carpenito at my school.

GeauxNursing · Feb 22, 2008

the diagnosis comes from your NANDA. "xyz related to ... as evidenced by...s/s"

upon assessing your patient, what is the priority? are there ABC's that need to be addressed? (airway, breathing, circulation)

gather your subjective, objective data. do these point to anything major that needs intervening? look at your NANDA.

subjective: pt states "it hurts when I breathe"

objective: blood pressure 165/88 (higher than baseline), abdominal incision from surgery

your NANDA would relate to controlling this person's pain.

ACUTE PAIN r/t (related to) surgical incision AEB (as evidenced by) pt states "it hurts when I breathe", BP 165/88

after the diagnosis, you need to focus on how to fix the problem. goals, interventions, then evaluation.

(hope this is all correct!)

Daytonite, BSN, RN · Feb 22, 2008

hi, hey~gurl~hey, and welcome to allnurses! :welcome:

in writing a care plan you must follow the steps of the nursing process in the order in which they occur. the five steps are:

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)
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)

before i can help you, you have to have done a thorough assessment of your patient and looked up information about their medical disease in order to learn about the signs and symptoms of it (in case you missed any when you did your assessment) and the pathophysiology (you will need that information when putting together some of your nursing diagnostic statements in step #2).

nursing diagnoses, goals and nursing interventions are all based upon the symptoms that the patient has. so, to help you, you need to post a list of the patient's abnormal data, or symptoms. just as a doctor diagnoses on the basis of the symptoms he sees, so does a nurse. we have the nanda taxonomy to help us in determining nursing diagnoses. each of the nanda nursing diagnoses has a list of symptoms (nanda calls them defining characteristics) and related factors which will help you in composing your 3-part nursing diagnostic statement.

you can also read about information on how to write a care plan on these three recent threads:

hey~gurl~hey · Feb 26, 2008

i need help coming up with some nursing diagnosis for my patient with a tia vs cva.... can some get me going in the right direction...thank you

LaceyRN · Feb 26, 2008

i need help coming up with some nursing diagnosis for my patient with a tia vs cva.... can some get me going in the right direction...thank you

first of all WELCOME to all nurses!

Second - we will be better able to guide you in the right direction if you give us assessment information on your patient. Objective and subjective data are needed so we can cluster the data and select an appropriate Nursing Diagnosis.

Do you have a careplan book?

Can you list the data you have for this pt?

Then we can better help you figure it all out. :)

Daytonite, BSN, RN · Feb 26, 2008

i need help coming up with some nursing diagnosis for my patient with a tia vs cva.... can some get me going in the right direction...thank you

Nursing diagnoses are determined by the symptoms that the patient has. What symptoms did you come up with after you did your assessment of the patient? I can't help you without knowing what your patient's symptoms are. Knowing that the patient had a TIA or a CVA is of no help to me.