Can someone help me with proofreading my care plan?

Hellllllo Nurse, BSN, RN · Oct 10, 2005

That is a super short care plan. When I was in school, ours were required to be 40-60 pages long with multiple pt problems, nursing diagnoses, interventions, etc.

What about the pts meds, lab tests, co-morbid conditions?

Is the pt diabetic? His age? No mention of the pt's psych-social condition, no hx or background.

The above is more like one small section of a care plan, not a whole one.

Is this all that's required now?

Also, look at this:

Problem statement: Ineffective Tissue Perfusion (peripheral)

related to interrupted venous flow resulting from statis dermatitis.

Manifested by:

a. errythematous, scaly, and roughness to integument bilaterally to lower legs.

b. +1 pulses posterior tibialis and doralis pedis pulses.c. Decreased capillary refill to bilateral lower extremities.

Desired goal:

1. The client will demonstrates adequate tissue perfusion.

As evidenced by:

a. The client will have palpable peripheral pulses.

b. The client will have warm and dry skin.

c. The client will have increase capillary refill

How can evidence of the desired goal be the same as Evidence of the problem?

"B" in pt problem should be changed.

What about activity level, ADLs, diet, nutrition, hydration, O2 status, medical dx, pt's understanding of his condition, pt's ability to communicate, pt teaching, etc.?

neneRN, BSN, RN · Oct 10, 2005

That is a super short care plan. When I was in school, ours were required to be 40-60 pages long with multiple pt problems, nursing diagnoses, interventions, etc.
What about the pts meds, lab tests, co-morbid conditions?
Is the pt diabetic? His age? No mention of the pt's psych-social condition, no hx or background.
The above is more like one small section of a care plan, not a whole one.
Is this all that's required now?
This is what we were required to do as a care plan when I was in school-just pick one of the pt's problems, usually the most significant one, and focus on it. We did have to do a care STUDY once a semester that was up to 50 pages long detailing all of the other problems/issues, but our weekly assignments were care plans as Janine has done above.
I can't remember all the specifics of doing a care plan, being that the last time I did one was in nursing school, but this one looks good to me.

meownsmile, BSN, RN · Oct 10, 2005

Its a good start, but dont you think you might want to include medications and their actions for patient response with regard to the goals.

Is there any lotions they are using to treat the dermatitis.

Are they on coumadin or lovenox as prophylaxsis re: DVT.

Is the patient on a antihypertensive? Will that help with edema of lower extremities re: decreasing vasoconstriction and increasing circulatory return?

Is the patient diabetic? How does controlling blood sugar and diabetes relate to the stasis dermatitis?

I remember we had to include as many medications as possible the patient was on and give why the patient was on them. If it didnt pertain to one of our nursing goals we had to include that goal also. I think mine took me 12 hours for a fairly short one,, if i got into a long one i would spend 16 hours (handwritten). uhggggg!!!!!

Hellllllo Nurse, BSN, RN · Oct 10, 2005

Wow, this is far different, and much less than I was required to do.

What about the the pulses?

I was required to do one huge, in depth care plan for each clinical rotation. That's 4-5

per semester.

Even if this is a small, weekly-type care plan, what about risk/actual infection, hydration, is pt diabetic, etc.?

I never had such a small care plan assignment, so it looks very incomplete and lacking to me.

Janinern84 · Oct 10, 2005

Oh yes, by far this is short. I have the rest typed, but this part is what I needed proofread. The meds, labs, and such are all a different part of the "Nursing Process Paper" is what they call it (I call it "I wish i was dead, i hate doing this kind of paper" lol)

What do you think I should change/fix? New interventions? They have to be NURSING interventions (so no labs or meds) just stuff you can do evry shift.

Please help

~Janine

Hellllllo Nurse, BSN, RN · Oct 11, 2005

How many nursing diagnoses do you need to do for this assignment?

Do you have a care plan book?

You could get a bunch more diagnoses, interventions for this pt from a care plan book. A good one would have many diagnoses suggestions pertinant to this pts medical diagnoses with several interventions/goals/outcomes for each.

Daytonite, BSN, RN · Oct 11, 2005

Janine SNLCC. . .this is my version of a care plan for your patient. Much of this came out of my head so I can't provide you with specific references, but you should be able to find these things in nursing textbooks. I would also have added some teaching nursing orders to prepare the patient for discharge but your plan didn't mention them. Watch your spelling of medical terms. If you are doing this on the computer it is much easier to put this into a Table format. Sorry it took me so long to get back to you. I got your care plan confused with your sister's.

Problem statement: Ineffective Tissue Perfusion (peripheral) to the lower extremities due to chronic venous insufficiency and manifested by erythema and scaling of the skin, increased tenderness, diminished posterior and dorsalis pedis pulses and decreased capillary refill.

Desired goal: The nurse will facilitate and promote venous return and minimize complications as evidenced by resolution of erythema, warm dry skin, and lessening pain.

Deadline: Upon discharge

Nursing Orders:

(1) Monitor dorsalis pedis and posterior tibialis with doppler q shift at marked points (an "X" should be placed over the pulsation sites where the bruit is heard best).

(2) An initial circumference shall be taken of both lower extremities at 10cm below each knee, those sites marked and the measurement recorded in the chart.

(3) Assess the color, temperature and circumference of both lower extremities q shift and record results in chart.

(4) Monitor q shift for any increase in leg pain, especially with movement, palpable cord in the calf and any increase in edema.

(5) Assess the skin of both lower extremities q shift for any evidence of skin breakdown or weeping of fluid.

(6) Keep lower extremities elevated above the level of the heart at all times while in bed. Make sure all linens upon which the legs rest are smooth and free of wrinkles.

(7) Teach patient to perform leg exercises every hour if allowed.

(8) Encourage the use of elastic support stockings.

(9) Instruct patient not to scratch pruritic areas with her fingernails, but to use a soft cloth or the soft pads of her fingers and to rub lightly if she must.

(10) Administer antipruitics as necessary.

(11) Administer analgesics for pain relief as ordered.

Rationale: (you supply the references!)

(1,2,3) Regular assessment of venous circulation enables detection of changes.

(4) Thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain. Leg measurement discrepancies >2 cm warrant further investigation. Homans' sign is not reliable (Herzog, 1992; Launius, Graham, 1998). Unfortunately, symptoms of already-developed DVT will not be found in 25% to 50% of clients' exams, even though the thrombus is present (Eftychiou, 1996; Launius, Graham, 1998).

(5) Broken skin weakens the body's defense against infectious organisms and increases the risk of developing cellulitis.

(6) Elevating the legs promotes venous drainage and relieves some of the leg pain caused by dependent positioning. Elevating the extremities helps to reduce edema which interferes with circulation and causes local congestion of tissues thereby preventing return flow of blood and metabolic wastes. Keeping linens wrinkle free reduces the chance of pressure injury to the skin and development of decubiti.

(7) Exercising the legs promote muscle pumping effect on the deep veins and improves venous return.

(8) Elastic stockings reduce venous pooling by exerting a constant even pressure over the leg and increases the blood flow into deeper veins of the leg.

(9,10) Constant scratching of skin with fingernails will lead to microtears in the skin which can become enlarged and form stasis ulcers and/or cellulitis.

(11) Relieving pain will make the patient comfortable and more likely to be compliant with medical regime.

truern · Oct 11, 2005

Daytonite, that's a GREAT plan!!

One caveat: the goal is supposed to be for the patient...ie, the patient will ___________,

Daytonite, BSN, RN · Oct 12, 2005

One caveat: the goal is supposed to be for the patient...ie, the patient will ___________,

You are talking about semantics here. While the Desired Goal is written in terms of nursing management, it clearly ennumerates the patient goals. I have been writing them this way for years.

In my world as a hospital nurse this is how my employer wants the care plan set up and worded. Your nursing instructors may be wanting you to use specific language in yours. Either way is correct. However, for your school assignments you should write your goal statement as you were instructed or your grade will suffer for it. I merely wanted to provide the OP and other readers of this thread with an example of what your employers might expect in a care plan.

Hellllllo Nurse, BSN, RN · Oct 12, 2005

janine snlcc. . .this is my version of a care plan for your patient. much of this came out of my head so i can't provide you with specific references, but you should be able to find these things in nursing textbooks. i would also have added some teaching nursing orders to prepare the patient for discharge but your plan didn't mention them. watch your spelling of medical terms. if you are doing this on the computer it is much easier to put this into a table format. sorry it took me so long to get back to you. i got your care plan confused with your sister's.
problem statement: ineffective tissue perfusion (peripheral) to the lower extremities related to chronic venous insufficiency secondary to medical dx manifested by erythema and scaling of the skin, increased tenderness, diminished posterior and dorsalis pedis pulses and decreased capillary refill.
desired goal: resolution of erythema, warm dry skin, and lessening pain.
deadline: upon discharge
nursing orders:
(1) monitor dorsalis pedis and posterior tibialis with doppler q shift at marked points (an "x" should be placed over the pulsation sites where the bruit is heard best).
(2) an initial circumference shall be taken of both lower extremities at 10cm below each knee, those sites marked and the measurement recorded in the chart.
(3) assess the color, temperature and circumference of both lower extremities q shift and record results in chart.
(4) monitor q shift for any increase in leg pain, especially with movement, palpable cord in the calf and any increase in edema.
(5) assess the skin of both lower extremities q shift for any evidence of skin breakdown or weeping of fluid.
(6) keep lower extremities elevated above the level of the heart at all times while in bed. make sure all linens upon which the legs rest are smooth and free of wrinkles.
(7) teach patient to perform leg exercises every hour if allowed.
(8) encourage the use of elastic support stockings.
(9) instruct patient not to scratch pruritic areas with her fingernails, but to use a soft cloth or the soft pads of her fingers and to rub lightly if she must.
(10) administer antipruitics as necessary.
(11) administer analgesics for pain relief as ordered.
rationale: (you supply the references!)
(1,2,3) regular assessment of venous circulation enables detection of changes in patient's condition.
(4) thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain. leg measurement discrepancies >2 cm warrant further investigation. homans' sign is not reliable (herzog, 1992; launius, graham, 1998). unfortunately, symptoms of already-developed dvt will not be found in 25% to 50% of clients' exams, even though the thrombus is present (eftychiou, 1996; launius, graham, 1998).
(5) broken skin weakens the body's defense against infectious organisms and increases the risk of developing cellulitis.
(6) elevating the legs promotes venous drainage and relieves some of the leg pain caused by dependent positioning. elevating the extremities helps to reduce edema which interferes with circulation and causes local congestion of tissues thereby preventing return flow of blood and metabolic wastes. keeping linens wrinkle free reduces the chance of pressure injury to the skin and development of decubiti.
(7) exercising the legs promote muscle pumping effect on the deep veins and improves venous return.
(8) elastic stockings reduce venous pooling by exerting a constant even pressure over the leg and increases the blood flow into deeper veins of the leg.
(9,10) constant scratching of skin with fingernails will lead to microtears in the skin which can become enlarged and form stasis ulcers and/or cellulitis.
(11) relieving pain will make the patient comfortable and more likely to be compliant with medical regime.

now that's more like it!

i would also add goal of maintaining blood glucose wnl (if pt is diabetic) and rationales, and providing adequate nutrition, re: tissue repair/healing, 02 prn, knowledge deficit, and add pt teaching.

but- did you just do her assignment for her?

meownsmile, BSN, RN · Oct 13, 2005

Janine,, why wouldnt you use med/labs,, there are a lot of nursing interventions for those to include in a care plan regarding medication side effects, fluids, monitoring. They all need to be included as nursing interventions on a care plan.

For instance,, a low potassium,, wouldnt you need to monitor for cardiac symptoms, encouraging food choices to help with potassium regulation. What about giving lasix,, a whole bunch of nursing interventions for that med.

I think your missing the boat if you dont include meds and abnormal lab values.