First "REAL" Clinical experience! Need some help NCP

[kwagner_51]

I have been at the hospital for the last 3 Mondays. On the 1st Monday I had an 80 y/o male who was going home before my clinical ended at noon. Last week I was with another student and we did care together on a 67y/o thyroidectomy patient. It was cool, but I didn't get to do much!

Today, I was assigned to a 23 y/o who wrecked his 4 wheeler. He had alot of pain and had a huge bruise on his outer Right Thigh. He also broke his left clavicle. I got to do total care!! He got a total bed bath, except for his privates, which he washed himself. [Although he wasn't very private about it!! :imbar] He couldn't walk b/c of the pain, but was able to move to the chair w/assistance.

Now I have to write my first care plan and I am SCARED!! This is what I am thinking of putting for the P.E.S. :

Acute Pain, r/t blunt trauma AEB moaning and the inability to walk.

What do you think? Is that a good diagnosis?

Thanks!

[PJMommy]

I might go more detailed on the pain: Acute pain r/t inflammation and prostaglandin release secondary to contusion and fracture AEB ... ?? Did he report or rate his pain? If so, then this is evidence also.

These may also work depending on your assessment:

- Risk for infection (pneumonia) r/t impaired mobility and ineffective cough secondary to pain....

- Ineffective therapeutic regimen ??

- Powerlessness r/t hospitalization, impaired mobility, pain...etc.

- Anxiety r/t pain, hospitalization, etc.

[shape0fmyheart]

Good for you! Today was also my first "sort of real" clinical, although I STILL have not even done a partial bed bath. I didn't do much today... but all I can worry about is "did I wash my hands enough?!" I swear I'm OCD when it comes to germs :chuckle

I'm still new at care plans but like PJMommy said you might want to get a little bit more detailed. Good luck!! I have a lot of trouble with those sometimes.