A few careplan questions.....

Jedi of Zen · Oct 17, 2007

Hey Jamie,

I think you've got the right idea by choosing the COPD instead of the Pressure Ulcer; I thought that the latter would be far easier to do, but I think it is actually quite the opposite. lol.

Question #1: Our instructor informed us to only do the care plan on one of these diagoses, so, do we need address both problems in the careplan, for example, under my objective data, would i say "pressure ulcer on coccyx" or since I picked COPD to do my careplan on, would i not mention it.

My understanding is that we just address one diagnosis per care plan. So in our module example, I don't think we're meant to address both the COPD and pressure ulcer together in one care plan. If this were occuring in the real world, we would simply make 2 (or more) care plans. At least, that is my understanding.

#2: How many Goal/Patient outcomes are ideal? just 1, with the following AEB's? or can you have more than 1?

I guess there may be instances in which more than one goal/outcome may be necessary, but I think just one will work. From my notes, I have written down that in lecture they really emphasized making the goal/outcome as simply a statement that address the diagnosis or problem. ie, "Take what's wrong and 'flip' it around", as Mrs. Roark said. :)

#3: On evaluation, I have listed goal achieved, and then do you just list one overall goal that was achieved followed by the AEB's?

Exactly. I think if anything we will simply have to make this information up, simply because this is an imaginary patient and so we don't even have the opportunity to do a "real" evaluation.

#4 Would a diagnoses be listed under objective data, since its gathered from the chart?

If you're referring to the medical diagnosis, I think that's a good question; I've been wondering the same thing myself. If the info was gathered from the chart, then I'm assuming that would be "nonverbal" and thus objective...so I guess the answer is yes. ?

Ok...Last thing!
My nursing Dx is Ineffective airway clearence R/T: Excessive presence of secretions, how does that sound?

Sounds awesome!

I may be wrong about some of these answers, so don't necessarily take my word on it. Hope this helps!

Jamie2887 · Oct 17, 2007

So with the turning around on the goal, you have my Dx, my goal is "Patient will be able to maintain a clear airway within 48 hours" with the

AEB- 1. demonstrating effective coughing techniques to help clear airway.

2. Patient having clear lung sounds after suctioning.

3. Patient having normal results with pulmonary function test

4. Patient stating, "i feel comfortable and am not having any diffilculties breathing."

I'm hoping that since this is our very first one, that they will be more easy on us.

Jamie2887 · Oct 17, 2007

Jedi, when were assessing for capillary refill, is it

Jedi of Zen · Oct 18, 2007

Jedi, when were assessing for capillary refill, is it
According to Potter and Perry it's less than 2. The notes may say 3 or something different, but I don't have time to find it either atm. Hope that helps! Oh and it indicates oxygenation, yes. ie the better the perfusion of blood, the better the oxygenation of tissues is. Your Goal and AEBs look good to me btw. Do you know if we get any kind of grade on the care plans, or is more just a matter of turning it in and not getting too many red marks?

Daytonite, BSN, RN · Oct 18, 2007

if you are going to address copd for your care plan you begin by following the nursing process. the nursing process is a way of problem solving. the first step is assessment. since this is a mock patient, you need to go to a resource on copd and list out the signs and symptoms of copd. understand that copd is a very general diagnosis and actually includes four medical conditions:

chronic obstructive asthma
chronic obstructive bronchitis
emphysema
chronic bronchitis with emphysema

so, you need to make a list of all the signs and symptoms of those conditions. they will be your objective data for this care plan. those signs and symptoms will ultimately become the aeb items in your nursing diagnostic statement as well as the things you will develop your goals/outcomes and nursing interventions for.

didn't your instructor give you direction on how many goals/outcomes you needed? at the minimum i would think you need at least one long term and one short term goal/outcome. the long term goal can relate back to the underlying definition of the nursing diagnosis itself. the short term goals are what you expect to happen as a result of the successful application of your nursing interventions.

when you finally decide upon a diagnosis to use you should verify its validity by checking a nursing diagnosis reference. diagnosing is nothing more than a decision or opinion you make after the process of examination or investigation of the facts. the facts, in the case of care planning, are the patient's signs and symptoms that you discovered during your assessment process. nanda has very conveniently supplied us with a taxonomy (a big word meaning a classification--an arrangement or ordering of the nursing diagnoses into some kind of logical groupings). they have given us descriptions of each diagnosis and provided the symptoms (nanda calls them defining characteristics) for each as well as related factors (etiologies). you need to refer to this information to assist you in making sure you have diagnosed someone with the correct nursing diagnosis, particularly when you are new at doing this. ultimately, a nursing diagnosis is a label that identifies the patient's problem.

here is information on ineffective airway clearance for you to look at in case you don't have a nursing diagnosis reference of your own. [color=#3366ff]ineffective airway clearance make sure you have the correct signs and symptoms (aeb items) attached to the nursing diagnostic statement. for example. ineffective airway clearance r/t retained secretions aeb dyspnea, rhonchi and wheezes in all lung fields, ineffective coughing and restlessness. this should not be your only nursing diagnosis for a copd patient. based on the symptoms there are a number of other nursing diagnoses that you should also have.

you can find more information on writing care plans and determining nursing diagnoses on these two sticky threads:

https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)
https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)

Jamie2887 · Oct 18, 2007

Thank you as always Daytonite! you always come to the rescue! I indeed do have some diagnoses books, 3 to be exact, in fact, I believe I could start my own nursing book library with everything put together :-D Alot of people seem to dread careplans, I found it actually quite fun, but tedious, its like a puzzle! On the diagnoses, after you R/T, can you leave it at that? or must there be a AEB? Also thank you for pointing out that I need to look up the symptoms of COPD to use for my objective data, I didnt even think to do that, I was just copying what little information they gave us from our mock patient sheet. so THANK YOU THANK YOU THANK YOU....I'm off too bed, second clinical tomorrow, and its my nursing home rotation, so I'm hoping to see some pressure ulcers, among other things! Goodnight

Daytonite, BSN, RN · Oct 18, 2007

Your nursing diagnostic statement needs to be what your instructor wants it to be. Clarify it with the instructor tomorrow. Most instructors want a 3-part statement (Nursing diagnoses-related factor-defining characteristics). Read the first chapters of your care plan books. They discuss the nursing process and the process of how to put a care plan together. Use the nursing diagnosis part of the books for reference. As I've said on other posts, a doctor wouldn't just look at a kid with a red nose and say, "you've got a cold" without doing any examination or basing his decision on a set of symptoms that defines what a common cold is. It's the same with nursing diagnoses. Until you learn what the signs and symptoms (defining characteristics) are of some of these nursing diagnoses you MUST use a reference book in order to make sure you are applying each nursing diagnosis to a patient correctly.