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We are doing concept care mapping here in Texas, Do thing you can help me?

Originally Posted by ELKMNin06

welcome guys

We are doing "mini mind maps" but basically the same thing as a care plan....

I have several saved on my computer if anyone is interested, the few dxs I can think of off the top of my head are:

gastric bypass
total knee replacement
metatastic cancer..or cancer
intestinal blockage

so if anyone wants to see the care plans/mini mind maps I have for those just let me know

[redefinition]

anyone know where i can find nanda dx for healthy newborns online?

[Christian_SN]

CARE PLAN THAT I WROTE, HOPE IT HELPS SOMEONE. IT IS NOT ONE OF MY BEST, BUT HOPE IT HELPS!

AEB CAN "NOT" BE USED WITH AN AT "RISK FOR" DX.

ASSESSMENT AND EVALUATION MUST GO WITH THE NURSING DX.

NURSING INTERVENTIONS MUST HAVE TIME PERIOD (EXAMPLE IS PRN OR Q4H PER MD ORDER)

Assessment

Sudden onset; shaking chill; rapidly rising fever of >101. Cough productive of purulent sputum (pink, thick).
Pleuritic chest pain aggravated by respiration/coughing
Dyspnea on exertion, no nasal flaring, or use of accessory muscles. all pulse sites palpable. IV antibiotics administered to patient as ordered by physician of vancomycim 0.5gm q6h
Oxygen per cannula, 5L with nebulizer q4h. Respirations 28 and shallow. Apical pulse is
weak at rate of 92. Pale and dry oral mucosa. Diaphoretic. Checks flushed, and hot. Inspiratory crackles in upper and lower chest. Fatigue and anxiety expressed. Non-smoker. no Hx of asthma. Hx of chest cold x2 weeks. Husband not at bed side. Side rails up x4. Call light within reach.


Nursing Diagnosis

Infection related to invading bacterial/viral organisms secondary to pneumonia as evidence by sputum pink and tick, Dyspnea, crackles in upper and lower field.


Desired Outcome
Throughout the hospital stay, the patient skin will:
Improvement of infection aeb , normal WBC, negative sputum culture on repeat culture

Nursing Intervention
Assess for predisposing factors; medication chronic illness
Assess vital signs closely monitoring temperature fluctuations
Obtain freash sputum for gram stain, and culture and sensitivity
Monitor gram stain, sputum, culture and sensitivity
Monitor WBC count
Assess hydration, Rationale
High doses of some medications have reduced resistance to infections
Continued fever may caused by drug allergy, drug resistant bacteria, super infections, inadequate lung drainage.
Determines correct antibiotics coverage for pt
Determines correct antibiotics for resistant bacteria
> levels indicate infection
Water loss is > with fever.


Evaluation
No change in the following:
Sudden onset; shaking chill; rapidly rising fever of >101. Cough productive of purulent sputum (pink, thick).
Pleuritic chest pain aggravated by respiration/coughing Dyspnea on exertion, no nasal flaring, or use of accessory muscles. all pulse sites palpable. IV antibiotics administered to patient as ordered by physician of vancomycim 0.5gm q6h Oxygen per cannula, 5L with nebulizer q4h. Respirations 28 and shallow. Apical pulse is weak at rate of 92. Pale and dry oral mucosa. Diaphoretic. Checks flushed, and hot. Inspiratory crackles in upper and lower chest. Fatigue and anxiety expressed. Non-smoker. no Hx of asthma. Hx of chest cold x2 weeks. Husband not at bed side. Side rails up x4. Call light within reach.

Goal NOT met
As evidence by:
No lab values obtained for ABG, WBC, sputum culture.

[AnnieJac]

I'm not sure when you first wrote this. Did you find the help you need? I have the Ackley orange book someone mentioned. I love it. It helps alot. I have done a few care plans if you'd like to see them. Its hard at first. The floor I'm doing my clinicals on doesn't even do a full care plan. They have a paper they mark off. Its interesting how different it is from floor to floor. Good luck!

[bm28083]

i also go to nursing school in the charlotte area except i finish in june of 06. and we use the R/T and AEB. I look at the R/T as what is the cause. that us usually the med DX so i just turn it into no med DX by strectching it out. apendicitis = infammation of the apendix. not the best example but the best i can come up with at 3 am. and the AEB are my symptoms.

[AnnieJac]

I have the Ackley book that some of them have mentioned here. I really like it because it also has NIC and NOC in it. I have the 6th edition and I know there is a 7th edition, but 6 seems to have everything the same. I really like it. We hand in care plans every week after clinicals. What amazes me is the floor I'm on doesn't use care plans like this. They have a sheet with lists and you just go thru and check stuff off. So I'm not quite sure how they actually do a plan of care. I can send you a sample of mine if you'd like. I'm not sure how to check my mail on here, but if you'd like, you can email me and I'll send it. Send me something on here and hopefully I'll get it. For something that sounds simple, its not that easy. So many technicalities. Good luck! Ann

[SNSS]

I always use a care plan book to write my nursing dx. It makes it so much easier. Usually the care plan books include a list of problems r/t to the patient's main complaint and they even include goals and interventions.

[bm28083]

i should have included in my last post that i use the ackley (orange) book also. but we are asked to make the care plan fit the pt we cared for.

[gr8nurse]

We use the same Care plan reference (Cox). I find it quite sufficient. You can't expect to find everything you need in a book. You have to be able to formulate things on your own. I'm not saying you don't...please don't get me wrong. I'm just so frustrated with students trying to find the easy way put and trying to short-circut the learning process. If you're a new student I can understand why you would need to reference more often. But looking for a care plan ready to turn in to be graded without your own thoughts and the nursing process behind itself is fruitless and will lead to nothing but failure, whether in school or on the floor. It takes time to learn this....and your own mental energy. I've seen too many people flunk out of our nursing program due to the same problem. It does come in time. And soon it becomes like breathing---completely involuntary. To be a nurse is to think like a nurse. Ask instructors for help--that's what they are there for.

[bm28083]

gr8nurse,

you are so right, i purchased the book i have now when i was in my second semester and having a lot of trouble with care plans. but now i find myself using it very little, more as a reference when i get stuck. i will also use it to make sure i have a comprehensive nursing diagnosis list to turn in for my patient diagnosis. we have to write a care plan for our top three problems. and, yes instructors are a very good resource. i could not begin to count the times i have shown them my problem list and have them say "have you thought about this..." and the light bulb goes off in my head.