Level one care plan help...please!

  1. Hello everyone!

    I need to write up a Teaching Care Plan for my OB rotation. The client is a 14 y.o. with a circumcised neonate.

    How does this sound? Where can I improve?

    Risk for infection R/T circumcision site

    LTG: the client will perform care to the circumcision site so as to keep it free of infection.

    STG: The client (mother) will explain 3 necessary procedures for keeping the circumcision site clean and infection free this a.m.

    I Assessment:
    1. assess clients cognitive level 1. to determine her ability to
    maintain the circumcision site.

    2. assess client for need of assistance w/ care of circumcision

    2. to determine if client has regained /will soon regain enough strength and coordination to care for the site.

    II Therapeutic:
    1. wash hands prior to care of the 1. to prevent infection
    circumcision site

    2. maintain dressing on circumcision 2. to prevent infection
    site as per MD instructions

    III Teaching:
    1. teach client about the purpose 1. to increase the clients knowledge
    and technique for dressing changes of preventing infections of site

    2. teach client about the s/s of infection and when to contact the nurse or doctor 2. early detection and intervention of infections is imperative in newborns.

    IV Referral:
    1. Social worker 1. to ensure the circumcision site is being
    properly cared for

    2. Community Health Center 2. to provide health care for low income
    families.


    I don't know how this compares to the format you are familiar with, but if you can offer any suggestions it would be greatly appreciated. Is RPbear around?


    With great thanks....

    EDITED TO ADD: I couldn't get the columns lined up in the post. The first column is for the intervention, the second is for the rationale. It looks confusing to me too...
    Last edit by Alexander on Apr 25, '04
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  2. 4 Comments

  3. by   gwenith
    2. to determine if client has regained /will soon regain enough strength and coordination to care for the site.
    Perhaps

    Determine if the client has the requisite psychomotor skills to perform required care.

    Umm - follow up by social worker not MD/GP???

    Otherwise looks good to me
  4. by   colleen10
    I would say that instead of your STG being that the mother "describes" (3) ways of keeping the site clean, she will correctly "demonstrate" (3) ways to keep it clean.

    Some may see it as splitting hairs, but you really only know that the client can perform the necessary technique when you observe them doing so.
  5. by   Pab_Meister
    Thanks Gwenith and Colleen,

    I think this is the fewest responses to a post I have ever received - I guess care plans are not liked much.

    I appreciate your comments!!! Thanks so much!!!
  6. by   purplemania
    the only thing I can add, besides addressing the pain, keeping patient hydrated (they cry a lot) and adding frequent diaper changes to keep site clean, is these sites:

    www.rncentral.com

    www.careplans.com

    www.nursing.about.com/health/msubplans.htm

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