Please help with my first care plan
- 0Hi everyone! I am currently working on my first care plan and need a little bit of help. I went to the hospital tonight and picked out my patient for my clinical day tomorrow. He is in the hospital for an abdominal trauma received from swallowing razor blades. I have completed the nursing diagnosis portion but am having trouble with creating a pathophysiology tree. We did not receive any help or direction on what the teacher is looking for, and I can't find any information in my textbook or online. I am thinking of writing "Abdominal Trauma" at the top of the page and then making a sort of flow chart explaining how the trauma could impact the different aspects of his health (lab values, problems w/ mobility, infection, etc.). Is anyone familiar with these pathophys trees and am I completely off track? Thanks in advance for all fo your help.
- 3,468 Visits
- 0patho would be on bipolar disorder. start with brief general definition/description of disorder. next include characteristics/most common s/s of bipolar. (include suicide attempts) then "my patient" exhibited __________ symptoms. (include suicide attempts). also, list most common treatments/therapies. list which ones patient has been treated with. include the surgery r/t abdominal trauma 2ndary to bipolar episode and attempt to commit suicide.
make sure to cite your references. usual good places, tabers dictionary (often incl. definition and patho) and your medsurg book.
hope this gives you and idea and place to start.
i have attached a very basic patho example. this example does not include the "patient exhibited" yet. hope it helps.Last edit by CRIMSON on Jan 13, '10 : Reason: upload example
- 0Jan 14, '10 by Daytonitei don't know how you could have come up with nursing diagnoses (nursing problems) for this patient if you had not already examined thoroughly what was going on with him. i always advise students to follow the nursing process when care planning. care planning is determining the patient's nursing problems and doing something about them. the nursing process is the problem solving method that we use to do that. the first step, assessment, includes doing the following activities before any diagnosing, the second step, is done:
- a health history (review of systems) - found in the chart
- performing a physical exam - not practical at this point
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - not practical at this point unless you review nursing documentation
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
- http://www.surgeryencyclopedia.com/f...l-surgery.html - general surgery
- http://www.surgeryencyclopedia.com/f...c-surgery.html - gastroenterologic surgery
- http://www.surgeryencyclopedia.com/c...y-surgery.html - emergency surgery
see this thread for more information and examples on the construction of a care plan: http://allnurses.com/general-nursing...ns-286986.html- help with care plans