I was assigned to put a care plan for a client with a broken leg.
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.
NOW is when it get complicated for me...
Under ASSESMENT DATA I have to list:
1- Subjective data
2- Objective data
Under NURSING DIAGNOSIS I have to list:
1- three Nanda nursing diagnosis (2 physical and 1 psychological)
2- Scientific rationale
Under PLANNING I have to list:
1- STG
2-LTB
3-INTERVENTIONS
Under IMPLEMENTATIONS I have to list:
1- five nursing interventions that were actually done for this client related to the problem.
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.[/quote']
You mean they expect you to learn the NANDA wording by osmosis or something? How are you going to learn them if you can't reference the book? I would go to the program director for this. It's not good teaching.
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.
Get the book anyway. If they won't teach you any better than that, you'll have to teach yourself. At least it will give you hints on what to think about, and you can use your own language for it. You don't have to give them everything you learn, just a little bit so they'll think you're awesome. You actually will be more awesome than they think, but they can find that out later. :)
I also am not allowed to use a care plan book. It made clinical work that much more difficult. Our schools explanation was that it didnt help us to critically think but instead ust look up something and copy it. I, of course believe that it could set me in the right direction. My program is a 2 year RN.
NANDA-I will, in fact, teach you a great deal about critical thinking, because it doesn't merely lay out your plans for you. It doesn't give you any plans at all, but teaches you how to assess for diagnoses so then you can determine, through other resources, what to do about them. You don't have to tell them you are using it as part of your own education. :)
I agree wholeheartedly that a lot of "care plan books" dish out canned "care plans" related to medical diagnoses, and those will not teach you as much by a long shot. In my profession I see a lot of "plans" that are related strictly to the medical diagnosis and have no evidence of individual assessment, and I think this is why.
edmia, BSN, RN
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