Desperately need help with careplans

http://www.rncentral.com/careplans/contents.html

this is a good website but you must remember that you have to individualize your careplans to your patient

Awesome resource on nursing diagnoses:

http://connection.lww.com/Products/c...ntCriteria.asp

Selected Care Paths Integrated with the Nursing Process

Eleven Steps to Care Planning

Nursing Diagnoses Grouped According to Functional Health Patterns

hi my name is Sarah and I am in nursing school to be an LPN I know how to write a careplan I'm just not sure how to write nursing interventions like how do I word them...I know what I wanna do we are learning using pretend patients and my patient is a woman and has a UTI I already wrote my diagnosis - Acute pain RT bladder infection AEB pt. states "It hurts when I pee" and my goal -Patient will state "It doesn't hurt when I pee" by 3/15/06 Now I need to write 5 nursing interventions I want them to be something like. assess pain on scale of 1-10, drink cranberry juice, teach pt. how to wipe from front to back and how to lower chances by drinking plenty of water. I still need one more. but I'm just not sure how to word it. Can anybody help? assignment is due by friday its wednesday if you have any input I'd really appreciate it!
Thanks,
Sarah

No bubble baths or douches-it changes the nayural flora of the vagina
If repeated cases of UTIs explain that intercourse can cause an infection and to urinate afterwards to flush out the semen

Well, you've got your nursing diagnosis; Impaired Skin Integrity, so next you need your "Related to," which will be specific to your pt, but some common ones are physical immobilization, mechanical factors (pressure, restraint,injury, surgery,etc), altered nutritional state (obesity or emaciation), alterations in turgor (edema), or skeletal prominence.

For your "as evidenced by," you'll use your assessment findings, i.e, does your pt have a wound, pain, itching, numbness, etc.

Next, your "desired outcomes," which would be how the pts diagnosis should show improvement, i.e., wound displaying signs of healing, pt participating in treatment plan, etc.

"Actions/interventions" are going to be your ongoing assessments; ex are identifying underlying condition/pathology, noting changes in wound, determining depth of injury, evidence of infection, evaluating risks for further injury, using appropriate dressings, repositioning schedule, encouraging mobilization, teaching.

So if your problem is a pressure ulcer, your care plan may look something like this;
Impaired skin integrity related to physical immobilization, pressure, and skeletal prominence as evidenced by open purulent wound to coccyx.

Desired outcome:
Pt will be free of purulent drainage within 48 hours. Will display signs of wound healing with wound edges clean/pink within 60 hours. Will participate in prevention measures and treatment program.

Actions/Interventions:
Assess wound with each dressing change (rationalerovides information about effectiveness of therapy and identifies needs)
Obtain culture of wound on admission (rationale; to identify pathogens and therapy of choice)
Administer ordered antibiotic (rationale:treatment of infection)
(And on and on, there are all kinds of actions/interventions for skin integrity, and this is usually the longest part of the care plan.)

I'm sure others can add to this, I haven't done a care plan since I was in school 5 years ago, but these are the basics that I remember.

Here is a sample of the last care plan I turned in. The first page is the "example" and the following pages show the 3 nursing diagnosis I chose, and the interventions/rationales that I included. Hope this helps.

The patient that I took care of this day had extensive facial lacerations, but was otherwise healthy...no other problems, and was ready to go home.

~J

Here are some links for you to check out. Mostly what I have are links to sample care plans. Somewhere on the forums here is a link to a care plan generator from elsevier publishers that is posted a number of times. I just don't have it in my database of websites. It may be in the allnurses thread link I've listed first--don't know, so you'll have to check it out.

When I wrote care plans I found it very helpful to know what the anticipated doctors orders were going to be as well as the signs and symptoms of the disease process that was going on. Then, I would base my nursing interventions on those things that I had to absolutely do because they were ordered by the doctor and those things that I could do indepedently as a nurse for the patient. All your nursing interventions must have a rationale, or a reason, why you are listing them.
(Updated 6/6/2009 - Most of the websites were no longer active - Daytonite)

• http://www.rncentral.com/nursing-library/careplans - from RN Central's Care Plan Corner. Here are care plans for 49 basic nursing problems. Also includes a template for a blank form you can print out. Each care plan gives you the language needed to write the nursing diagnosis statement, suggestions for outcomes, and nursing interventions for that particular problem.
• http://www.cnsonline.org/www/archive/ms/ms-07.txt - sample care plan for an MS patient

1. Collect your patient data, including subjective (what pt states) and objective (what you see). In texts - they may be called "defining characteristics."
2. Cluster those data & see the related factors causing #1 (i.e. medical diagnosis, pathophysiology, current health status).
3. Look at reference for nursing diagnosis which has your defining characteristics & related factors.
4. State your goal / patient outcome with measurable evidence (what do you want patient to demonstrate or verbalize and when is a realistic time frame to accomplish this patient outcome). This is focused on patient's behavior, not the nurse's behavior.
5. Interventions. What will you (the nurse) perform that will address the patient data and lead to the patient outcome.
6. Evaluation. Look at your goal / patient outcome / measurable evidence. Did you meet the criteria? If yes, then outcome met. If no, look at interventions that need revision.

• Hope this helps.

Oral care is a problem for most as many nurses don't get to have a patient that needs oral care. I happened to have had extensive oral surgeries and oral problems secondary to radiation therapy and happened to be in nursing school with a dental hygienist who wanted to change professions! Most all oral care is aimed at comfort such as relieving pain. Outside of that, treatment is usually aimed at healing whatever has gone wrong and preventing it from happening again. Without preventative care people lose their teeth. I've put together some links for you to check out. One of the links gives the events that occur that lead to tooth loss when left untreated. Do you know the extent of the damage of the tooth structures? Is there gingivitis present? If so, then, treatment needs to be started for that. You can find information on the treatment of gingivitis or tooth abscess by doing a search on the MedLine Plus website. Knowing the pathophysiology of tooth decay is a good place to start. A child is going to be a good candidate for teaching of good oral care.

http://www.fpnotebook.com/DEN/Sx/TthPn.htm - Tooth Pain

http://www.ada.org/public/topics/decay_faq.asp - Frequently asked questions about tooth decay by the American Dental Association

http://www.adha.org/kidstuff/index.html - this site is maintained by the American Dental Hygienists Association and it is for Kids to teach kids how to take care of their teeth.

http://www.simplestepsdental.com/SS/ihtSS/r.WSIHW000/st.31843/t.31886/pr.3.html - how a tooth decays – the steps of tooth decay

http://kidshealth.org/kid/talk/qa/cavity.html - What's a cavity? an information sheet for kids