Trouble with Nursing Care Plans

  1. 0
    Ok so here is the deal...I am having trouble with these lovely things called nursing care plans. My teacher wants a nursing diagnosis, a long term goal, a short term goal, 3 interventions and 3 rationales. I am having difficulty coming up with a second short term goal with different interventions than the first short term goal...can anyone help me?

    My first diagnosis is: Impaired Skin Integrity r/t scratches AMB itching and disruption of skin surface (epidermis).
    My short term goal is: Client's skin integrity will not diminish within next 6 months.
    My interventions are: Assess skin on chest and upper extremities every morning.
    Apply lotion to itchy area 3 times a day.
    Apply clean, dry clothing over affected area daily.

    My second diagnosis is: Impaired Physical Mobility r/t decreased muscle strength AMB limited ROM and unsteady gait.
    My short term goal is: CLient will increase muscle strength from a level 3 to a level 4 on the muscle strength scale by 12/18/08.
    My interventions are: Assess for pain before, during and after activities.
    Assist with active ROM in mornings on Monday, Wednesday and Friday.
    Participate in PT/OT 5x week.

    I am stumped because I feel like I covered everything in my first short term goal.
    Any advice would be appreciated! Thanks so much!
  2. 18 Comments so far...

  3. 0
    Our short term goal has to be within 24-48 hours.
    Did she give you parameters for the time?
  4. 0
    No she did not specify a time.
    She is not big on the time factor since this is our first care plan.
  5. 1
    How about
    • safety
    • patient teaching
    • ambulation techniques and measures to prevent complications to help prepare patient and family for discharge
    • demonstrate ambulation regimen and note the date. have patient and family members perform a return demonstration to ensure continuity of care and use of proper technique

    • inspect pts skin every shift, describe and document skin condition, and report changes. this provides evidence of the effectiveness of the skin care regimen.
    • remind pt not to scratch to avoid skin injury.
    • encourage pt to express his feelings about his skin condition to enhance coping.
    • instruct pt and family in the skin care regimen to ensure compliance.
    • supervise pt and family in the skin care regimen. provide feedback. practice helps improve skill in managing pts skin care regimen.
    HOPE THAT HELPS!
    katydid_flip likes this.
  6. 2
    you've got some problems with these diagnoses. let me go through them.

    my first diagnosis is: impaired skin integrity r/t scratches amb itching and disruption of skin surface (epidermis).
    "itching" is not evidence of damaged skin which is what impaired skin integrity is. it is a related factor, a cause, of it. "disruption of skin surface" is another way of saying impaired skin integrity--this is double talk, gobbledygook. you need evidence, signs and symptoms, of this skin breakdown. what does it look like? describe it.
    my short term goal is: client's skin integrity will not diminish within next 6 months.
    what did you just write? that makes no sense to me. first of all, 6 months is not short term. secondly, "skin integrity will not diminish" sounds like a mouthful of marbles. what the heck does that mean? i can't even picture skin diminishing. if you had described this skin breakdown you would be able to describe what this ideal skin would be looking like in a week which is how long it takes a scratch to heal.
    my interventions are: assess skin on chest and upper extremities every morning.
    assess skin on chest and upper extremities every morning. . .and observe for what? what are the signs that skin is healing? what specifically do you want to look for when you assess
    apply lotion to itchy area 3 times a day.
    apply clean, dry clothing over affected area daily.
    where is the affected area?
    --------------------------------

    my second diagnosis is: impaired physical mobility r/t decreased muscle strength amb limited rom and unsteady gait.
    clarify "limited rom" and spell it out, i.e. can't bend left knee more than 15 degrees, can't bear weight on right leg or can't raise right arm above the level of the shoulder. describe it and be specific.
    my short term goal is: client will increase muscle strength from a level 3 to a level 4 on the muscle strength scale by 12/18/08.
    if muscle strength is an etiology (underlying cause) of this problem (impaired physical mobility) and getting rid of it would do away with the problem, why are you making this a short term goal? is this reasonable?
    my interventions are: assess for pain before, during and after activities.
    neither of your two symptoms suggest the patient has pain.
    assist with active rom in mornings on monday, wednesday and friday.
    describe the specific rom exercises and to what body parts.
    participate in pt/ot 5x week.
    again, get specific.
    what are you going to do about this patient's unsteady gait? there are nursing interventions for a patient whose walk is unsteady (gait belt, walker, one person assist when ambulating, have patient use call light when needs to get up). and what about the limited rom? does he need referral to pt first? does he need assistive devices such as a cane or walker? do things like the bedside table need to be placed on his left or right side because one arm is stronger than the other (i don't know since you don't specify what the rom problem was)? if walking to a chair is difficult but he can transfer from bed to chair, does a bedside chair need to be placed a certain way for him so he can independently get to the chair? you have to stop thinking about collaborative interventions that involve pt and think about what you are going to do to help this person be more independent and live with and improve the cards they got dealt. we are nurses. that is what we do.
    HospiceNurseRN and katydid_flip like this.
  7. 0
    Thank you for all your advice. It is helpful.
    I am working on fixing everything now. The care plan is due Tuesday and I should be meeting with my instructor tomorrow to go over it!
    Thanks again.
  8. 0
    Quote from katydid_flip
    Thank you for all your advice. It is helpful.
    I am working on fixing everything now. The care plan is due Tuesday and I should be meeting with my instructor tomorrow to go over it!
    Thanks again.
    also... i was having a big trouble with writing nursing care plans, until i discovered the nursing section in borders! they have a ton of nursing diagnosis books... every NANDA approved nursing rx out there (our school only lets us use NANDA approved ones.) you can look up your stuff from the book and reword it. just be sure to cite a list of references if you get it from the book!
  9. 0
    We are only allowed to use NANDA diagnoses as well!
    What all does this book you are talking about have in it?!
    Does it have goals and interventions as well as the diagnosis?
    Thanks for the info.
  10. 0
    Quote from katydid_flip
    We are only allowed to use NANDA diagnoses as well!
    What all does this book you are talking about have in it?!
    Does it have goals and interventions as well as the diagnosis?
    Thanks for the info.
    Hey... yeah, just go to borders or barnes and noble and look in the nursing section. there will be some book that has to do with nursing diagnoses. the one i like to use is by the author carpenito-moyet. it gives you the rx, short term goals, long term, interventions and rationale.
  11. 0
    Thank you for that information. SOunds like an amazing book and just the thing I need to help me out!
    What are the requirements for your rationales?
    Mine have to come from our text book and has to be a scientific reason for doing the intervention. It can't be the logical/simple reason for doing it. Does that make sense?


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