The basis of a nursing care plan is the nursing diagnosis.Critical thinking exercises for nursing students involve drafting hypothetical nursing care plans.A nursing diagnosis is similar to a medical diagnosis in that it analyzes the patient's needs.
Step 1: The patient's symptoms should be observed.
Take a look at the patient's injuries or symptoms.A description of the problem the patient seems to be having is based on the signs and symptoms you see.If you have a patient with a traumatic brain injury, they may seem confused and confused.They don't seem to understand where they are or why they're in the hospital.Don't worry about using official terminology.You can "translate" your observations later.Get down what you say in your own words.
Step 2: Discuss how the patient is feeling with their family.
Information from the patient as well as those around them are included in your actual nursing diagnosis.Information about the patient's behavior and appearance can be provided by family and friends.They can tell you how the patient's condition is affecting them.To understand the patient's response to their condition, ask them questions.If you have a patient with a traumatic brain injury, you might ask if they know where they are or why they're there.To get a better understanding of their connection to reality, you might ask them what day it is, or who the president is.The patient's problems may be impacted by the response and attitude of friends and family.If the patient's spouse is stressed out or anxious, it may increase their anxiety.
Step 3: Evaluate the patient's response to their symptoms.
Look at what the patient has done to alleviate their symptoms and how they are handling any pain or loss of functioning.Consider the patient's treatment of people around them, including loved ones and health care providers.If the patient lashes out at loved ones or health care providers, they may be in a lot of pain or have high levels of anxiety.
Step 4: There is a distinction between objective and subjective data.
The patient tells you how they feel.Their perception can't be verified.Observations that are measurable and verifiable use scientific methods to produce objective data.Data to support your actual diagnosis can be either objective or subjective.The basis of your diagnosis can be formed by objective data.It is important for your diagnosis and overall care plan to have subjective data regarding the patient's pain level.The patient might say they felt dizzy or confused.The subjective data can be quantified by using objective data such as the patient's blood pressure and pulse.
Step 5: There is a problem that your nursing diagnosis will address.
Patterns are found in the data you've collected.There are many signs and symptoms that point to the correct diagnosis.The focus should be on the experience of the patient and those around them.The individual is reflected in a nursing diagnosis.Two patients with the same condition will have different diagnoses.Let's say your patient has a concussion.What your patient needs to help with this condition will be included in your nursing diagnosis.It could include regular checks to make sure the patient is awake.Ask questions such as "what day is it?"Where are you?To make sure the patient is oriented with time and place and to watch for signs of confusion.Patients often have more than one problem.Each problem should be diagnosed separately.
Step 6: The source of the patient's problem can be found.
Figure out why the patient is having that problem after you've diagnosed the problem.This will help you figure out what nursing interventions will work.Suppose you have a diagnosis of chronic pain.There is a patient with a recent injury.The source of the pain is most likely caused by the injury to the spine.Guidance can be provided by the patient's medical diagnosis.If you have a patient recently diagnosed withCOPD, that disease is most likely the source of your nursing diagnosis of a persistent cough.Patients may have more than one diagnosis.To make it easier to address the needs of the patient, it's best to rank them in order of severity.They are listed in order of concern on the doctor's synopsis.Being aware of the patient's changing needs is normal for the order to change over the course of treatment.
Step 7: Evaluate the patient's health.
Determine factors related to their current condition by reviewing the patient's chart and records.Also relevant are lab reports and conversations with other health care team members.Smoking may be a factor in the patient's persistent cough or difficulty breathing.The patient and their loved ones can give you information about the patient's medical history and recent behavior.
Step 8: Potential problems should be included in determining related factors.
List the symptoms or issues the patient might experience while undergoing treatment based on your knowledge of their condition.The problems the patient has tend to cluster together with other symptoms.If you have a patient with a persistent cough, sleep pattern changes related to the cough could be a problem.Predicting potential problems helps you tailor treatment for the patient.
Step 9: You can find the most appropriate nursing diagnosis.
Look at the official terminology for the problem.You have to use the NANDA-I and any other nursing textbooks.You can find official terminology for the needs and condition of the patient by writing it down.Potential outcomes and nursing interventions that are appropriate for your patient can be looked up once you have a nursing diagnosis.Consider how each applies to this patient.
Step 10: For your diagnosis, bring the related factors together.
Related factors or causes of the patient's problem are listed in the next part of your nursing diagnosis.If you don't already know them, look up the standardized terms in your textbooks.The second part of your nursing diagnosis is related factors.After the specific diagnosis, write "related to" (also abbreviated "r/t") or secondary to, followed by a list of sources or causes you've found for that problem.Suppose you have a patient with chronic confusion after a traumatic brain injury.You could write this up as "chronic confusion secondary to traumatic brain injury"You need to work within the doctor's diagnosis.Refer to the working diagnosis if the diagnosis is not final.
Step 11: The data should be summarized in an "AEB" statement.
"As evidenced by" is a common nursing abbreviation.There are characteristics that show the problem you've diagnosed by sifting through the data.List of characteristics to look for that are related to a particular diagnosis will likely be found in your textbooks.You should only include the characteristics that you have observed.The data is subjective or objective.