Assistance with Care Plans!

Published

Specializes in ICU, CCRN.

I really want to work on making great care plans... I know it should not be as hard as it seems to be right now... I'm in 3rd semester of my RN program and have yet to master this...last semester we did maybe one care plan =/

Any tips to making a great care plan?

I just made this one any productive criticism would be great.

"Nursing Dx: Disturbed thought process related to visual & auditory hallucinations a.m.b. pt statement " I often see people looking at me and then when I look back its really a tree", pt report he hears voices when playing basketball, pt seen in hallway speaking to himself

Goal/Outcome:

  • Pt will adhere to medication regimen fully by 2weeks
  • Pt will verbalize absence of voices & hallucinations within 4weeks

Intervention:

  • Monitor med. Regimen observing for S/E
    • R: identifies min. does necessary to reduce psychotic symptoms

    [*]Educate pt on medication (S/E, when to take, when to call doctor, when onset)

    • R: Aides w/ pt compliance to med. Regimen

    [*]Establish a therapeutic nurse-client relationship

    • R: provides emotionally safe milieu and enables interpersonal interaction

Evaluation:

  • Goal met pt adhered the medication regimen fully by the 2week mark
  • Goal partially met, pt has verbalized diminished voices & hallucinations at 4weeks but still present at times "

Up Vote Up Vote ×
+ Add a Comment