Broken leg care plan please help

classicdame, MSN, EdD · Jun 3, 2013

I am going to state the obvious. Get your textbook. Take one topic at a time and determine how to respond to the questions. Make a list of all the things you will be looking for in regards to care for the patient (pain, nutritional intake, VS, etc). I think you might be overwhelmed at the big picture. Break it down and then ATTACK!

Esme12, ASN, BSN, RN · Jun 3, 2013

Welcome to AN! The largest online nursing community!

Simply put.......Care plans are the recipe card on how to care for someone....logically, rationally. They tell you what is important for any particular patient....and what needs to be looked at, treated, considered first. Care plans as a nurse is a standard recipe card .....you already "know" how to bloom yeast.....as a student you look up, include the how to, and "learn" how to bloom the yeast so you can remember the how to for the future.

Care plans are all about the assessment OF THE PATIENT.....the whole patient. What is the patient assessment? What do they need? Have they had any procedures? What brought them to the hospital? How long have they been hospitalized? What are their vitals signs? What is their main complaint? Tell me about your patient!

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

These sheets may help you out.....OUR daytonite made them (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Now tell me about your patient....what are their vitals....what are the labs...what is their main C/O? What brought them to the hospital?

Now tell me what your assessment showed.

Esme12, ASN, BSN, RN · Jun 3, 2013

Case Scenario:
"SK, age 72 female, was visiting her daughter who has 2 huge dogs. They were running and heading right for SK. They both hit her and she 'went flying over the 2 of them'. SK hit the ground and 'it took out the breath of me and I thought that I had sprained her right ankle'. She went to ER the next day because she could not walk on it. The ankle was purple, swollen, and painful to touch.
VITAL SIGNS RESULTS (versus Normal Adult Vital Sign Range)
T= 97.8 F (36.5 C to 37.0 C or 96.5 F to 99.9 F)
P= 96 (60 100 beats/minute)
R= 22 (Between 12 and 20 breaths/minute)
BP=134/76 (120/80)
Treatment for broken leg:
The ER doctor performed and examination of the right ankle and ordered an x-ray. The x-ray indicated a fracture and placed SK in a cast. She was given crutches and told not to do weight bearing for several days. An appointment is made for SK with an orthopedic surgeon for the next day. The MD also ordered Motrin for her for pain.

First of all shame on the MD only Motrin for pain????

Second .....Do you have a care plan book? Which one?

Ok what is important here....this patient fell. She fractured her ankle. She has 2 large dogs....who when excited knocked her over.

Her ankle is purple, swollen, and painful to touch. Her temp is normal. Her heart rate is a little fast, her resps a little fast, and her B/P a little high....Why would that be? What are the physiological signs of pain/anxiety?

What is important top know about the care of a fractured/injured ankle? What instructions will this patient need?

She has a new cast what is important information about a new cast? What would be important things to teach the patient about the new cast and cast care?

What about crutches? What does the patient need to know about crutches and crutch walking

Under ASSESMENT DATA I have to list:
1- Subjective data
2- Objective data

Objective data is information that you can perceive using your owns senses. you can see, hear, smell, feel, sometimes taste, and sometimes measure objective data.

Subjective data is information supplied to you by the subject, or patient. They are things that you cannot yourself perceive with your senses of sight, sound, smell, or touch. for example, pain. a patient tells you they have a pain in their leg. That is subjective data. It is based on the patient's statement. You cannot see, hear, smell, or feel the patient's pain. However, you can see a grimace on the face of someone in pain. The grimace on their face would be an objective observation.

Under NURSING DIAGNOSIS I have to list:
1- three Nanda nursing diagnosis (2 physical and 1 psychological)
2- Scientific rationale

Lets use the most obvious...pain

Acute Pain: NANDA-I Definition

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage ; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Pain is whatever the experiencing person says it is, existing whenever the person says it does .

Defining Characteristics

Subjective: Pain is a subjective experience, and its presence cannot be proved or disproved. Self-report is the most reliable method of evaluating pain presence and intensity. A client with cognitive ability who is able to speak or provide information about pain in other ways, such as pointing to numbers or words, should use a self-report pain tool (e.g., Numerical Rating Scale [NRS]) to identify the current pain intensity and establish a comfort-function goal.

Objective: Pain is a subjective experience, and objective measurement is impossible. If a client cannot provide a self-report, there is no pain intensity level. Behavioral responses should never serve as the basis for pain management decisions if self-report is possible. However, observation of behavioral responses may be helpful in recognition of pain presence for clients who are unable to provide a self-report.

Observable pain responses may include loss of appetite and inability to deep breathe, ambulate, sleep, and perform ADLs. Pain-related behaviors vary widely and are highly individual. They may include guarding, self-protective behavior, and self-focusing; and distraction behavior ranging from crying to laughing, as well as muscle tension or rigidity (Puntillo et al, 2009). Clients may be stoic and lie completely still despite having severe pain. Sudden acute pain may be associated with neurohumoral responses that can lead to increases in heart rate, blood pressure, and respiratory rate (McCaffery, Herr, & Pasero, 2011). However, physiological responses, such as elevated blood pressure or heart rate, are not sensitive indicators of pain presence and intensity as they do not discriminate pain from other sources of distress, pathological conditions, homeostatic changes, or medications (Arbour & Gelinas, 2010; Gelinas & Arbour, 2009; McCaffery, Herr, & Pasero, 2011). Behavioral or physiological indicators may be used to confirm other findings; however, the absence of these indicators does not mean that pain is absent (McCaffery, Herr, & Pasero, 2011)

Related Factors (r/t)

Injury agents (biological, chemical, physical, psychological)

NOTE: from Ackley: Nursing Diagnosis Handbook, 10th Edition

Under PLANNING I have to list:
1- STG
2-LTB
3-INTERVENTIONS

Short term goal...pain free or in reality the pain will be decreased fro a 8 to a three with the interventions of.....what? Pain med, right? elevate the leg, right? Apply ice to ankle....tight?

Now your turn......

Under IMPLEMENTATIONS I have to list:
1- five nursing interventions that were actually done for this client related to the problem.

What did you do to help them......give a pain med....elevate foot, apply ice.......

Under evaluation I have to list:
1-Goals
2- Interventions
3- Goals met, not met or partially met.
4- Outcome

Your goal was to relive pain, Did you do that? How did you do that? Why why not? What happened in the end?

Does this make sense?

JoJoJoJo · Jun 5, 2013

Thanks so much!

JoJoJoJo · Jun 5, 2013

Thanks a lot. NOW it makes sense to me. I was so lost!!! I do not have a care plan book and my instructor does not allow us to use one.

Imagine that, for someone in the intro semester. But you definitely helped me to break it down. Thanks again, you are awesome!

Esme12, ASN, BSN, RN · Jun 5, 2013

Thanks a lot. NOW it makes sense to me. I was so lost!!! I do not have a care plan book and my instructor does not allow us to use one.
Imagine that, for someone in the intro semester. But you definitely helped me to break it down. Thanks again, you are awesome!

That is CRAZY!!!!!!!!!!!! :confused:

Then how are you supposed to do your care plan? How are you getting your NANDA information?

Is this a Rn/ LPN? 2 year/4 year? Accelerated?

JoJoJoJo · Jun 5, 2013

According to the instructions, I should be searching in adult nursing books. Is basic RN plan. Thanks again!!!

Esme12, ASN, BSN, RN · Jun 5, 2013

SMH......wow......I know they want you to learn how to research for what you need in medicine but frankly that is putting you at a huge disadvantage....do they let you use a NANDA book?

What they don't know couldn't hurt them besides it is an adult book as well.... :speechless: Did I just say that? Shame on me.

Your school is wrong.

ADN2B · Jun 6, 2013

Get the darn book to guide you where to go in your textbook.

nurseprnRN, BSN, RN · Jun 6, 2013

You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses, though every day in AN you'll see plaintive queries begging, "I have a patient with congestive heart failure. What are three nursing diagnoses for this?" There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, as you go along in school and are ever tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

JoJoJoJo · Jun 7, 2013

Thanks, but I am not allowed to use a Nanda or care plan book, the instructor is able to 'smell' when something came out of a book and that will give you 0 for a grade. Thanks again.