[Crux1024]

I just finished my first care plan... I know it needs work, and this is just the rough draft that I have to hand in Thursday. Tfinal Careplan is not due until Next thursday...

I linked it here if any feel like reading it. A critique would be nice...please, dont be too harsh..LOL..

[momx4]

We were always taught that the first nursing intervention must be to ASSESS the situation. Just because you cant do any interventions until you know all available information. I would say ( i might be wrong) but intervention 2-5 sound are more like goals not interventions. They need to be what you will do with or for the patient. So instead of saying "Patient will" say something like "encourage the patient to...."
Oh these care plans gave me such issues in the beginning and as a senior student I still struggle in the correct wording. We were also taught to put time frames on interventions and goals.
I hope I helped. It gets better the more you do. I used to be up all night doing them. Now it only takes me a few hours,lol.
Good luck! You are doing great!

[Melissa B RN]

I agree with momx4 that interventions 2-5 sound like goals or outcomes. I think if you change the wording as she suggested your care plan will be just fine. You did a good job!!

[mysterious_one]

great job for your first care plan,
I agree with the others and I would like to add, that in your goals is where you want to state: the patient will ....
Also goals have to be measurable, realistic, and there has to be a time frame when you expect the pt. to reach these goals.
Keep up the good work .

[Crux1024]

Thanks guys..

I will revise...

[moongirl]

I am still sitting here with me mouth hanging open at how SHORT it is!

My careplans that were required were 8 pages long and included 2 md's dx, 2 nursing dx, a problem list, pathophys of the dx, meds, labs, a full head to toe,psychosoc assessments, interventions,
rationales(cited), outcomes and education. We had one due each and every week.To do a good job and get an A was 7-8 hours of work. Holy smokes.
If I get over my shock and awe, I will go back and critique it

[mysterious_one]

Originally Posted by moongirl

I am still sitting here with me mouth hanging open at how SHORT it is!

My careplans that were required were 8 pages long and included 2 md's dx, 2 nursing dx, a problem list, pathophys of the dx, meds, labs, a full head to toe,psychosoc assessments, interventions,
rationales(cited), outcomes and education. We had one due each and every week.To do a good job and get an A was 7-8 hours of work. Holy smokes.
If I get over my shock and awe, I will go back and critique it

This is her first one , she probably will have to built on it or just chose to share one part of it with us.

[Daytonite]

Sorry it took me so long to respond to this. I've been ill, but more correctly I was out of town this weekend and I'm having a heck of a time catching up on posts since I always go to the nursing student assistance forum first.

Your nursing diagnosis is Anxiety R/T clients fear of changes in mental status AEB client's verbalization of "forgetting myself" and of "not wanting to be like others here that can't do anything for themselves". You've got a problem with the related factor and the way it is stated. The way this stuff is worded is EVERYTHING according to NANDA. The related factor is the etiology, or cause behind the symptoms, leading to the anxiety. Think of it as a title for the symptoms, if that helps give you a better picture. Having some medical information on the patient would be helpful in determining some etiology here as well. Based on what you have provided this statement can very simply be changed to: Anxiety R/T change in living environment and threat to mental ability AEB client's verbalization of "forgetting myself" and "not wanting to be like others here that can't do anything for themselves". Sounds better to me anyway.

Now, I have a problem with what you have listed in your box of "Supporting Data". I don't know what your nursing instructors have told you to put there. But, I know what supporting data is. It's the abnormal assessment data, also called symptoms, NANDA calls them the defining characteristics, that you have based your choice of nursing diagnosis upon. It, in my view, should be exactly what follows "AEB" in your nursing diagnostic statement. So, you have two subjective data

1. forgetting myself, and
2. not wanting to be like others here that can't do anything for themselves

You've got no objective data. At least none that you included in your nursing diagnostic statement and applied nursing interventions to. What physical symptoms of anxiety did you observe in this patient? Surely, you saw something! Maybe one of these: nervousness, irritability, dread, insomnia, exaggerated startle response, easily distracted, unable to concentrate, muscle twitching, tremors, restlessness, shakiness, fatigue, muscle aches or tension, paresthesias, palpitations or tachycardia, shortness of breath, dyspnea on exertion, chest pain, sweating or cold palms diaphoresis, choking sensation, dysphagia, heartburn, nausea or vomiting, abdominal pain, anorexia, frequent urination, dizziness, lightheadedness, faintness, headache. My NANDA reference lists a whole lot more too. They are listed on this web page: Anxiety and I bet if you look at it you'll see the patient has a few of them.

In looking at your nursing interventions I see the first one listed as teaching relaxation techniques. Keep in mind that all your interventions must relate to the supporting data, or symptoms. I didn't see anything in your supporting data about the patient stating they were tense (opposite of relaxed), fidgeting, restless, irritable, overexcited or any other adjectives that would warrant relaxation techniques. This, again, goes to the objective symptoms of anxiety. I think this is something you need to correct. Something about that patient's behavior made you think she needed this kind of intervention, so think about what that was and commit it to paper. Does she have problems coping since that was a rationale you attached to this intervention? Nothing about coping was mentioned in your supporting data.

Your supporting data doesn't mention that the patient feels isolated. That is an important symptom you need to include as well if it exists. Get a statement the patient made about feeling isolated into your subjective symptoms.

Do you see where I am going with this? Everything has to fit and link together like a jigsaw puzzle. Your interventions are good.



Now, goals. . .goals are always a prediction of what you want to see happening after you have instituted your nursing interventions. While I think your short term goal is OK, I've got a better one (I've worked in long term care). One of your interventions is for her to participate in residential activities and I want you to look at the rationale you attached to that because it pretty much wrote the goal for you. I would tweak it even more and say something like

Within one week client will know the name and be able to discuss some personal data about of one resident with whom she eats meals.

I have a problem with the word "stress" used in the last long-term goal since stress was not mentioned anywhere else in the care plan except in the goals and one intervention. Wasn't mentioned in the symptoms as all. I know, because I did a "word seek" of your document. Just as you are feeling a lot of stress right now, you might want to change the word "stress" to "anxiety".

Very good effort for a first time! I would be interested to know what your instructor has to say.

[Crux1024]

Thanks all for the help Everybody. I did revise a little, but I got the rough draft back already and it wasnt that bad..I just have to adjust some, but It should be ok.



Daytonite -

My objective data was what I guessed is causing her anxiety (the living in an LTC). While I was interviewing her, she expressed numerous times about her fear of dementia and alzheimers. We were told that our subjective data could be just a quote, if it directly referred to our diagnosis. Which is why i did.. I see now that I can in put other info. Do you think it would be okay if I left the quote there and added on to the Subjective data?

I feel that If I said "threat to mental ability", I would have to be specific on what I meant (with the alzheimers and dementia).. I guess I would just assume that no one would understand what I was referring to.

Looking over the defining characteristics on that link you provided, I definately see some that would apply to her that I hadnt even thought of.

On My Careplan, It looks like I was using anxiety and stress interchageably...lol. I guess I assumed that if youre anxious, you must be stressed. I know thats not true. I was just soo out of my element here trying to write my first one up..

THANKS FOR ALL THE HELP!!

[Daytonite]

Subjective data is usually a quote or statement made by the patient. As long as you put quotations around it, you're good to go with it. Yes, you can leave the quote there and add other subjective data. But, I think you also need to add some objective data as well. There should be objective signs of her anxiety as well.

The "threat to mental ability" would be an etiology, a label you are placing on her fear of "forgetting herself" and "not wanting to be like the others there". So you have been specific on what she meant. You quoted her. This is also reflective of the change in her living environment. She just moved in and her anxiety over it is showing. What you lack is objective data. What was her behavior when you talked to her? Did she look at you? Did she avoid eye contact? Was her speech hesitant? Did she fidget with her fingers? Think about this. These are indications of someone who is under stress and anxious about their situation. They also tend to not answer questions that are asked, but skirt around them.

The thing with care plans is that where nursing diagnoses are concerned, the wording that is used is important. NANDA stresses this and they spend hours developing the wording that should be used. This is why it is good to use a care plan book as a reference since the wording is already laid out for you. I have a copy of NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 published by NANDA International which costs under $30 and is what I refer to a lot to verify related factors and defining characteristics for the nursing diagnoses. Most of the current care plan and nursing diagnosis books have this same information and they pay a royalty to NANDA to reprint it. Some books rewrite it a bit. Still, it's good to use something for a reference so you are using the nursing diagnosis correctly. Anxiety is one of the harder ones to use, I think. Any of the psychosocial ones are. It's far easier to use one that relates to a patient's physical illnesses. Just stick to what NANDA lists under this diagnosis and you will be OK with it. Don't try to tuck something in that doesn't fit in or needs to go into a totally different diagnosis. Anyway, after reading what you had on your care plan, I suspected you are using some kind of care plan resource anyway. Am I right?