Help with Care Plans - page 22

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Are you scratching your head or are you maybe even ready to tear your hair out over how to come up with care plans? Here are some words of wisdom from our own beloved Daytonite. Care Plan Basics Don't focus your efforts on... Read More


  1. 0
    Quote from amops
    i need help in writing this care plan,
    the writing of a care plan follows the steps of the nursing process. the first thing you need to do is to collect together (make a list) all your assessment data of the patient. nursing assessment includes:
    • a health history (review of systems)
    • performing a physical exam
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
    the next thing you do is make a second list from that which includes everything that is abnormal. it is the abnormal data that is the evidence of the patient's nursing problems which you will probably know better as nursing diagnoses. once you know what the nursing problems are you can then develop nursing interventions to treat them. and, that is a care plan.
  2. 0
    Man, you guys are amazing! This site gets better and better every day. I am so glad I found it!!

    Here is my own deal...
    I am in my first semester. We are behind because of insane snow storms, but we are rushing to catch up. We went over care plans in class, but of course, doing it at home, by yourself changes the game. The book I have doesn't follow how my prof wants it. I mean, the end result will be the same, but getting there is a whole diff map. I might just be confusing myself though. Anyway, any guidance would be great.

    my lady is 84, taken care of at home by daughter. Admitted with dehydration and urosepsis, -dark yellow, oderous urine. Stage II ulcer on sacral-2cm diam 1cm depth, no drainage, tender surrounding, oriented x2, pale dry skin, poor skin turgor, dry mucous membranes, 140/98, HR=106, resp 20,98.8, weight 102-usually 115, thin extremities, minimal right leg movement, unequal palmmar grips-right weaker, red 2 cm spot on right elbow, minimal appiteite, refusing liquids, occassionally confused and disoriented in the past few months, incontinant of bowel and urine in the past few weeks. confined to bed.

    So, she wants 2 nursing Dx--I selected:
    1. Nutritional imbalance of less than the body requires related to the refusal of fluids and minimal appitite as reported by daughter,manifested by dark orderous urine, dry skin and poor skin turgor.
    Planning: STG=Mrs Blank will consume adequate nutrition and increase fluid intake.
    • Observe clients ability to eat and relationship with food. Refusing to eat may be the only way Mrs Blankcan express control and it may be a symptom of depression.
    • Coordinate plan of care with health care provider, psychologist, Mrs Blank, and registered dietitian. Successful nutrition careplanning is amultidisciplinary approach throughout the continuum of care.
    • Encourage fluid intake. Older adults need eight 8oz glasses per day of fluid from beverage and food intake. Concentrating intake in morning and early afternoon is acceptable to prevent nocturia.
    • I am pretty sure we should have 4 of these. I thought I saw something about making meals social. And would like to add that, or maybe personalizing menu based off of results of observation. Maybe she needs soft foods, or more frequent smaller portions?
    Then there is the matter of evaluations. I am supposed to just put what I want to happen? Such as "Skin is less dry, Turgor has improved." And Evaluation of goals is "Mrs Blank has improved physical parameters of nutrition"?

    I feel like I am all over the place trying to piece this stuff together.

    My second nursing Dx, is " Management of innefective family care related to care of skin integrity manifested by stage II pressure ulcer called a blister by care taker daughter."

    I feel like maybe I am skipping my main focus. Maybe it should be the urosepsis, but I know my nursing dx should not include medical Dx,.....but maybe it should be somehwere? I am just lost. Any help wouldbe amazing. Thanks folks!
  3. 5
    Quote from mercuryrawks
    man, you guys are amazing! this site gets better and better every day. i am so glad i found it!!

    here is my own deal...
    i am in my first semester. we are behind because of insane snow storms, but we are rushing to catch up. we went over care plans in class, but of course, doing it at home, by yourself changes the game. the book i have doesn't follow how my prof wants it. i mean, the end result will be the same, but getting there is a whole diff map. i might just be confusing myself though. anyway, any guidance would be great.

    my lady is 84, taken care of at home by daughter. admitted with dehydration and urosepsis, -dark yellow, oderous urine. stage ii ulcer on sacral-2cm diam 1cm depth, no drainage, tender surrounding, oriented x2, pale dry skin, poor skin turgor, dry mucous membranes, 140/98, hr=106, resp 20,98.8, weight 102-usually 115, thin extremities, minimal right leg movement, unequal palmmar grips-right weaker, red 2 cm spot on right elbow, minimal appiteite, refusing liquids, occassionally confused and disoriented in the past few months, incontinant of bowel and urine in the past few weeks. confined to bed.

    so, she wants 2 nursing dx--i selected:
    1. nutritional imbalance of less than the body requires related to the refusal of fluids and minimal appitite as reported by daughter,manifested by dark orderous urine, dry skin and poor skin turgor.

    planning: stg=mrs blank will consume adequate nutrition and increase fluid intake.
    • observe clients ability to eat and relationship with food. refusing to eat may be the only way mrs blankcan express control and it may be a symptom of depression.
    • coordinate plan of care with health care provider, psychologist, mrs blank, and registered dietitian. successful nutrition careplanning is amultidisciplinary approach throughout the continuum of care.
    • encourage fluid intake. older adults need eight 8oz glasses per day of fluid from beverage and food intake. concentrating intake in morning and early afternoon is acceptable to prevent nocturia.
    • i am pretty sure we should have 4 of these. i thought i saw something about making meals social. and would like to add that, or maybe personalizing menu based off of results of observation. maybe she needs soft foods, or more frequent smaller portions?
    then there is the matter of evaluations. i am supposed to just put what i want to happen? such as "skin is less dry, turgor has improved." and evaluation of goals is "mrs blank has improved physical parameters of nutrition"?

    i feel like i am all over the place trying to piece this stuff together.

    my second nursing dx, is " management of innefective family care related to care of skin integrity manifested by stage ii pressure ulcer called a blister by care taker daughter."

    i feel like maybe i am skipping my main focus. maybe it should be the urosepsis, but i know my nursing dx should not include medical dx,.....but maybe it should be somehwere? i am just lost. any help wouldbe amazing. thanks folks!
    first of all, if you read any of the information in the first part of this thread you would be following the nursing process in writing this care plan. care planning is about determining what the patient's nursing problems are and doing something about them. this patient was admitted with dehydration and urosepsis and in looking at the assessment information you gave she has plenty of symptoms of these, so you shouldn't ignore them.

    step 1 assessment

    • dark yellow, odorous urine
    • pale dry skin
    • poor skin turgor
    • dry mucous membranes
    • refusing liquids
    • minimal appetite
    • 140/98, hr=106
    • weight 102-usually 115
    • thin extremities
    • minimal right leg movement
    • unequal palmar grips-right weaker
    • red 2 cm spot on right elbow
    • oriented x2
    • occasionally confused and disoriented in the past few months
    • incontinent of bowel and urine in the past few weeks
    • confined to bed
    step #2 determination of the patient's problem(s)/nursing diagnosis
    • deficient fluid volume r/t loss of fluid aeb dark yellow, odorous urine, pale dry skin, poor skin turgor and dry mucous membranes
    • imbalanced nutrition: less than body requirements r/t inability to ingest food aeb weight of 102, thin extremities, minimal appetite (whatever that is, you need to be more specific about this)
    • total incontinence r/t dementia aeb unaware of incontinence of bowel and bladder
    • impaired physical mobility r/t ??? (need a cause here, probably her dementia) aeb minimal right leg movement, confinement to bed and unequal hand grips
    • impaired skin integrity r/t pressure and incontinence aeb stage ii ulcer on sacrum that is 2cm in diameter 1cm in depth and tender to touch and 2 cm red spot on right elbow
    • acute confusion r/t ??? (probably dementia) aeb disorientation to ??? and confusion to ??? over the past few months
    step #3 planning (write measurable goals/outcomes and nursing interventions) - remember that your goals are a reflection and anticipation of what will happen when your nursing interventions are performed. so, think about what nursing interventions you will be doing when putting your goals together. your nursing interventions target each of the aeb items of your diagnostic statements. just as a doctor treats signs and symptoms of a disease, we also treat the symptoms of a nursing problem.

    - - - - - - - - - - - - - - -
    nutritional imbalance of less than the body requires related to the refusal of fluids and minimal appitite as reported by daughter,manifested by dark orderous urine, dry skin and poor skin turgor
    • this is not an official nanda diagnosis the way you have written it. i know what you mean, however.
    • this diagnosis has to do with intake of nutrients insufficient to meet metabolic needs (page 74, nanda international nursing diagnoses: definitions and classifications 2009-2011). dark ordorous urine, dry skin and poor skin turgor do not have anything to do with the intake of nutrients and are inappropriate symptoms to pair with this diagnosis.
    • you also need to be more specific about a minimal appetite. we are scientific. report a percentage of what she is eating.
    management of innefective family care related to care of skin integrity manifested by stage ii pressure ulcer called a blister by care taker daughter
    • i have no idea what this diagnosis is. it is not nanda.
    • the related factor has nothing to do with management of care.
    • the symptoms also have nothing to do with management of care.
  4. 0
    God I miss those days! I loved my clinical days. Enjoy nursing students for only this time around you will only have 1 or 2 patients! lol
  5. 0
    Just only use Risk for Injury and Risk for Infection....its always those two diagnosis
  6. 0
    I am new to this site, but I am needing some help with care plans. I have seen a lot of examples and I have done care plans before, I'm just struggling with this one. I am trying to use a "readiness" diagnosis. I wrote my diagnosis as: "Readiness for enhanced coping r/t past divorce AEB verbalizing the desire to start counseling." I don't know if it is written correctly and I am needing help with desired outcomes! Thank you!!!!
  7. 0
    Hi i am currently in my first semester in an accelerated nursing program, and i am writing a careplan on a patient with morbid obesity, chronic lower extremety lymphedema, CHF, PVD, Lung canver and many others. it has been emphasised over and over in class and at clinical that ABC's should be the priority on all patients. i was wondering if a nursing diagnosis with first priority: Impaired gas exchange will be a good one? and do i need to follow the ABC rule strictly when writing a care plan?
  8. 0
    Hello Peeps, I need help with care plans for a stroke patient. I am currently doing a nursing care study of a stroke patient, a 73 yr old male, right sided MCA infarct, with left sided hemiparesis, dysathris of speech, expressive ashasia and hemianopia. You help and advice will be most appreciated. Thank you guys and gals.
  9. 0
    thank you for the infos.!!!
  10. 0
    any other good websites for nursing concept maps?


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