Care Plan Basics: 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. There are currently 188 nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. What you need to do is 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. How does a doctor diagnose? He/she does (hopefully) a thorough medical history and physical examination first. Surprise! We do that too! It's part of Step #1 of the nursing process. Only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. Each medical diagnosis has a defined list of symptoms that the patient's illness must match. Another surprise! We do that too! We call it "critical thinking and it's part of Step #2 of the nursing process. The NANDA taxonomy lists the symptoms that go with each nursing diagnosis. 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: 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) Now, listen up, because what I am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. The nursing process itself IS a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. One of the main goals every nursing school wants its RNs to learn by graduation is how to use the nursing process to solve patient problems. Why? Because as a working RN you will be using that method many times a day at work to resolve all kinds of issues and minor riddles that will present themselves. That is what you are going to be paid to do. Most of the time you will do this critical thinking process in your head. For a care plan you have to commit your thinking process to paper. And in case you and any others reading this are wondering why in the blazes you are being forced to learn how to do these care plans, here's one very good and real world reason: because there is a federal law that mandates that every hospital that accepts Medicare and MedicAid payments for patients MUST include a written nursing care plan in every inpatient's chart whether the patient is a Medicare/MedicAid patient or not. If they don't, huge fines are assessed against the facility. You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids. Let me give you a simple example: 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). Can you relate to that? That's about as simple as I can reduce the nursing process to. But, you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish. 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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. At all times. And that is within the spirit of Step #1 of this whole 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. 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 care plan 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. 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 (Ex: Activity Intolerance) is actually a shorthand label for the Patient Problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every NANDA nursing diagnosis has a definition). Activity Intolerance (page 3, NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008)

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities (does this sound like your patient's problem?) Defining characteristics (symptoms): abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness Related Factors (etiology): bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle I've just listed above all the NANDA information on the diagnosis of Activity Intolerance from the taxonomy. Only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information. In order to choose nursing diagnoses, you also need to have some sort of nursing diagnosis reference. There is some free information on the Internet but it is limited to about 75 of the most commonly used nursing diagnoses. There is a post that has the weblinks to them (see post #109 on the thread: http://allnurses.com/forums/f205/desperately-need-help-careplans170689.html One more thing . . . CARE PLAN REALITY: Nursing Diagnoses, nursing interventions and goals are ALL based upon the patient's symptoms, or defining characteristics. They are all linked together with each other to form a nice related circle of cause and effect. You really shouldn't focus too much time on the nursing diagnoses. Most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. The nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.

1. They DO NOT have related factors. Instead they have risk factors. Risk factors are environmental [conditions] and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event (page 333, NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008). 2. You use a "Risk for" diagnosis when you "think" a specific problem "might happen" to the patient 3. Since these are potential, or anticipated, problems there are no defining characteristics (signs and symptoms) to use as evidence to support the diagnosisas there are with actual problems. So your nursing diagnostic statement has only two parts: o the nursing diagnosis label o the risk factor(s) 4. You have to have a very clear and defined idea of the problem you are attempting to prevent, know it's signs and symptoms and preventative measures. 5. Interventions for these nursing diagnoses are limited to: o strategies to prevent the problem from happening in the first place o monitoring for the specific signs and symptoms of this problem o reporting any symptoms that do occur to the doctor or other concerned professional o if symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis 6. As a general rule, these types of nursing diagnoses do not have the same priority as actual nursing problems. Actual problems are usually attended to first. 1. make a list of your patient's symptoms o jaundice o stage 2 pressure ulcer on the sacrum (What were the measurements, any drainage, appearance?) o history of multiple falls o severe diarrhea (How many a day?) o multiple stones and stent placed per ERCP on 4/17 (where were these stones and were they the cause of the jaundice?)

Flagyl, 250 mg (why was she getting Flagyl? What kind of infection was being treated?) o Darvocet bid (Where was the pain that this was addressing?) o ASA 81 mg / day o 15 liters O2 non rebreather mask (Did you get any lung sounds or blood gas results?) o Pulse was 93, respirations: 36, then went to Resp. 42 & shallow, BP 60/36 pulse 90 o pulse ox 73 o not responding other than opening her eyes once in awhile o restless o her care was changed to "comfort measures" - DNR o all meds d/c'd, morphine 1-2 mg q 2 hours, IV 2. using that list you will o determine your patient's 4 nursing problems (nursing diagnoses) if you had more lung assessment information other diagnoses could be used - these are prioritized by Maslow Impaired Gas Exchange (supporting evidence: pulse ox of 73, restlessness, pulse of 93) Ineffective Breathing Pattern (supporting evidence: respiratory rate of 42 and pulse of 93) Diarrhea (supporting evidence: severe diarrhea - needs more description) Impaired Physical Mobility (supporting evidence: not responding other than opening her eyes once in awhile, placed on Morphine you also need more description that she is not moving or turning on her own) Impaired Skin Integrity (supporting evidence: description of the Stage II sacral ulcer) Chronic Pain (supporting evidence: ?, getting an analgesic) Risk for Falls (supporting evidence: history of multiple falls) o determine goals - based upon the results you expect from the nursing interventions you will be ordering (writing goal
o

statements: http://allnurses.com/forums/2509305post157.html) determine nursing interventions - ordered for the supporting evidence (symptoms) associated with each nursing diagnosis

To use Death Anxiety the patient has to be making statements to you or the others on staff about concerns about her death, yet you have listed nothing about that. To diagnose, you really need to use a nursing diagnosis reference since every nursing diagnosis has a set of defining characteristics (symptoms) and your patient must match with at least one of them. I used NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 to doublecheck the supporting evidence (defining characteristics) for the diagnoses I chose above. In my opinion, the two top priority diagnoses that I would treat are where most of the nursing care would be focused: keeping the airway open and keeping the patient turned 1. Ineffective Breathing Pattern 2. Impaired Physical Mobility The choice of what to use for priority diagnosis depends on the behavior the patient is exhibiting. You seem to indicate that she has pain, but my thinking is that her breathing is probably more of a problem which the morphine will help. Here are links to information about end of life care, but they are not nursing sites. They will give you an idea of what "comfort care" involves.
Hope this helps ! Well be going over it every day at clinicals.