Need Help w/ Care Plan

  1. Morning!

    I have a 78 y.o male. who has MS w/a neurogenic bladder, CAD, COPD, HTN and Tic doloreaux. He requires ISC q 4 hrs. He has been in extended care facility for the past 10 years.
    Our instructor "suggested" that my care plan be Impaired urinary elimination.
    I really don't know how I can build from this. What could be an expected outcome, nursing interventions my eval/SOAP? (charting)

    I apologize if this seems "easy to figure out" this is my very first pt. ever and my first "offical care plan."
    I am truly lost.
    Would it be eaiser to build from one of his other med dx.?

    Thanks in advance,
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  2. 3 Comments

  3. by   JnJTyson
    I know how you feel. I'm graduating LPN school in May. I remember sitting in class on the first day talking about care plans thinking "this is NEVER going to make sense to me"
    Once you've done a few, you'll get the hang of it. My dx may not be the NANDA approved wording, but you can always get it out of a care plan book.

    1. Fluid Volume deficit/overload (which ever he may be..probably overload)
    2. Self-care deficit
    3. Fear/Anxiety r/t death/dying
    4. Impaired Gas exchange for the COPD....

    Also..a few little hints that have helped me on those care plans for pts who really don't have much going on:
    --Don't forget the wonderfulness of the words "Risk for" they don't have to have it..but they could get it! =0)
    --Standard hospital dx you can always use: fear/anxiety rt hospitalization, risk for infection r/t surgical incision, IV cath, foley and such. Risk for nutrition alteration r/t decreased appitite, NPO status for x hours, anxiety. for the older ones, risk for fall r/t whatever.

    There are so many..some nursing dx books have indexes with dx categorized by diseases..really a big help.

    And don't forget to look way down deep. Don't just deal with the body..think about the mind, some of those psych dx really apply to people with no mental problems. My favorite dx I have ever done was: energy field disturbance

    The girl was a hardcore new-age girl. She was vegan, did all the herbal teas and pills, only natural foods, was into chakras...and so on. I had to put it in there. She was a really interesting pt to take care of. =0) anyhow..hope all that helped!

    Jules
  4. by   JnJTyson
    You only have to do 1 nursing dx per care plan?? We've always had to do 4!!

    Also..if you don't have a care plan book...get one..it will tell you everything you need to include with that dx!!
  5. by   Chickp
    Quote from JnJTyson
    You only have to do 1 nursing dx per care plan?? We've always had to do 4!!

    Also..if you don't have a care plan book...get one..it will tell you everything you need to include with that dx!!
    Thank you so much for your input.

    We are not "allowed" (during this present clinical) to do "risk" dx.
    I have several care plan books. Ackley/Ladwig etc....
    It is just like you said, once it "clicks" (which I know it eventually will) I will be fine. The more I do them the easier it will become.
    We only have to pick one nrg dx. from our Gordons functional health plans.
    I can't imagine having to do 4!!!!

    Thanks again for your help!

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