mosby has a care plan constructor on line that can be used in conjunction with their book. you may find that helpful. i think there may be rationals listed also, if not you normally must give rationals for your interventions.
there are other free on line care plan constructors as well as companies that you pay a specific price to and use their care plan constructor.
i am sorry, but i do not quite understand what the pt is in the hospital for. apparently she had a fall and had surgery.
what we know is you have a 92 year old female, post op. what are the problems that you see?
off the top of my head i believe you mentioned blood pressure is an issue. she received a tranfusion; what was she transfused with. is she receiving an iv; if so, what for. she is very weak; what does this tell you; what is her o2 status; is she in pain? is she bed bound? what are the issues with limited mobility--and risks. your objective data will be put on your care plan; the subjective data that you find out from the patient is also put on the care plan.
you have so many issues going on that you could do many nursing diagnosis. remember to prioritize your diagnosis...life threatening issues first; then issues -- remember maslow's hierarchy of needs. make sure your diagnosis reflects your data and the data will reflect your goals and interventions. only you can come up with a nursing diagnosis and it is based on what you see, hear and yoru data.
i found a general care plan as an example so you have an idea what i am talking about. i don't remember which book or site i obtained this plan, but this is not rocket science. your care plan is based on your patient and what you will do for the patient.
the issue for this care plan is hip fx - fracture of hip, with risk for complications, including infection of surgical site, pain, impaired mobility, embolism. will remain free of complications related to hip fracture, such as contracture formation, embolism, immobility through review date. surgical incision will heal without s/sx of infection or breakdown by review date. will return to prior level of function after wound healing and rehabilitation by review date. assess/record/report to md prn s/sx of hip fracture complications: · contracture formation · embolism s/sx (cyanosis, pain, petechiae, tachycardia, tachypnea, dyspnea) · infection at surgical site · impaired mobility · unrelieved pain anticipate and meet needs. be sure call light is within reach and respond promptly to all requests for assistance. modify environment as needed to meet current needs: · non-slip surface for bath/shower · bed in lowest position with wheels locked · floors that are even and free from spills, clutter · adequate, glare-free light follow md orders for weight bearing status. see md orders and/or pt treatment plan. pt, ot evaluation and treatment per orders. assess/evaluate/provide with/monitor use of adaptive devices as needed: · fracture pan · gait belt · abduction pillow · walker · wheelchair · elevated toilet seat administer pain medications as ordered and monitor for effectiveness. notify md of pain unrelieved by ordered meds. administer treatment to surgical wound site as ordered. monitor for s/sx of infection and notify md prn. obtain and monitor lab/ diagnostic work as ordered. report results to md and follow up as indicated. activities accommodations: · avoid weight-bearing activities · schedule activities around therapy needs · use activities to divert attention from pain · notify nurse if c/o pain during activities spend time talking with resident. allow to discuss feelings related to loss of function, independence. provide adequate diet to meet nutritional needs. provide supplemental vitamin c, zinc, protein as ordered to promote wound healing. resident education: · s/sx of infection · rehab process · fall prevention · medications · transfer/wt bearing techniques
i found the info below posted in allnurses. apologies to the author as i did not get her name. you may find the info helpful. "suggestions for writing a care plan like i tell my students when i have them, i don't go from forward to back on my nanda's but backwards to forwards.
i think...okay what is the probelm as i see it (and remember, just one probelm at a time). so in my brain i say..hmmmm i am · worried about skin problem, and the fact the pts buttocks are getting red.
what did i do or what do i want to do? [implementation] okay · get them off the area, · turn frequently, · have it checked every shift, · use pillows and · bed position changes to float the area, and · even request a air bed. okay cool...i have my implementations already, and i will know if they work [evaluation outcome à] by less redness and no breakdown...wow, got my evaluation/goals of care!
now i work backwards...got my implementations and evaluation so let’s fill in the gaps. · this person has a red buttock area...okay that is my as evidenced by à "presence of warm moist reddened bilateral buttock areas" cool got my aeb! two more steps to fill in!
related to..hmmmm why is this happening...of course, mobility is bed bound...easy! so now one step left....hit the nanda dx's and find one that fits!!!!!! impared skin integrity! perfect! now lets take all this and move it all forward....
[color=#002060]care plan à impaired skin intergity r/t decreased mobility (bed bound), aeb moist warm reddened areas on bilateral buttocks. [color=#002060]implementation: · turn pt q 1-2 hours, · use of pillows to float the area as much as possible, · monitor skin q shift and alert wound care prn, · discuss use of air mattress with the md.
[color=#002060]evaluation/goals: pt will have lessening of redness on bilateral buttocks and keep intact skin.
i find if you go backwards things seem a little to the point better then trying to fill in the gaps from front to last! break it down...what did you see (that will typically be your first thing but will be you aeb), what do you want to do (implementations), how do you know it works (evaluation), why is this happening (keep it simple...remember one probelm at a time per nanda dx and that is you r/t), and find a nanda dx! then fit it all in .
i have taught this to students and had them ace care plans! heck, i could have also gone dietary on this one, but that would be a whole new nanda care plan as it should be...only address on simple probelm at a time, and keep it simple...simple breaks things down into workable things that you actually can achieve in your evaluation/goal area!" here is some guidelines that my former professor posted for our class re care plans. every program has their own requirements, but this guideline is as good as any.
i. assessment column
1. make sure your data is in clusters of related data.
2. make sure you include only those data clusters that relate to the nursing diagnosis (both parts: the problem and the etiology(ies)).
3. make sure you identify objective or subjective next to each piece of data.
ii. nursing diagnosis
1. your care plan will consist of working through a plan of care for 1 nursing diagnose.
2. the nursing diagnosis will consist of 2 parts:
the problem – highest priority.
the etiology – what is causing the problem?
what is contributing to the problem?
3. can have more than one etiology in the nursing diagnosis statement, but only one problem.
1. must focus on the problem part (the first part) of the nursing diagnosis statement.
2. must be in future tense.
3. must be client oriented. start the goal with the words “the client” or “the client’s_____”
4. include a time frame for goal achievement.
5. the goal should be a broader statement than the outcome criteria.
iv. desired outcomes
1. these are the guidelines by which we will measure whether or not we have met the stated goal.
2. these need to be specific and measurable indicators.
3. these need to focus on the problem part of the nursing diagnosis, not on the etiologies.
v. nursing interventions
1. these focus on the second part of the nursing diagnosis statement – the etiologies.
2. be sure to make the interventions specific for the pt.
3. identify if the intervention is independent, dependent or collaborative.
4. include a rationale for each nursing intervention.
5. you must have at least 5 interventions for each nursing diagnosis.
1. should explain how performing the intervention helps resolve the problem in the nursing diagnosis.
2. be sure to identify the resource and page number where the rationale was found.
3. must include a reference page that lists the references you used for your rationale (must use the apa formatting).
1. include the date of the evaluation.
2. make an entry discussing where the client is at this time in relation to each desired outcome.
3. then, identify if the goal has been:
(this is based upon your discussion of the desired outcomes)
4. then, identify what you will do with the plan of care:
continue the plan
discontinue the plan
revise the plan