is this care plan acceptable?

setingle · Nov 22, 2008

my instructor told me to email it to her, but of course, she has not gotten back to me on what i need to fix and/or change. so as a first year nursing student this will be the first actual care plan that i have had to wirte. i am extremley nervous and do not know i meet the expectations. i am nervous about my wording because i know that i tend to veer toward "slander" instead of nursing terms. please if you have anyknowledge in care plans skim over mine and let me know if it is horrible or acceptable.
no full identifiers or full names so do not worry.

nursing diagnosis: disturbed sensory perception (visual, auditory)

related to: legal blindness

major: as evidence by: uses cane

requires assist in ambulation

glasses, hearing aid

nursing diagnosis: at risk for impaired skin integrity

related to: urinary incontinence, personal care deficit (toileting)

impaired verbal communication, hemorrhoids

complete on clinical day #3

care plan

nursing diagnosis

outcome / goals

nursing intervention

evaluation

nursing diagnosis:

disturbed sensory perception (visual, auditory)

related to:

glaucoma, legal blindness

as evidenced by:

uses cane, requires assist in ambulation, glasses, hearing aid

patient receives optimal functioning within limits of visual impairments as evidence by ability to care for self, to navigate environment safely, and to engage in meaningful activities. goal will be met by 12-25-2008.

-orient patient to environment

-make sure there are no changes to patients environment

-provide adequate lighting

-encourage use of hearing aid

-identify self when entering room and space

-build on patients remaining vision

- orient to time, place, person, and surroundings

- converse with and touch the client frequently during care if frequent touch is within the client's cultural norm

-keep call light button within reach

-pay close attention to patients emotional needs

- pay attention to background noise and reduce it to a minimum when attempting conversation

-speak slowly and distinctly, use simple sentences

-lower pitch of voice and speak in tone that does not include shouting

evaluation not possible because of amount of time with patient.

care plan

nursing diagnosis

outcome / goals

nursing intervention

evaluation

nursing diagnosis:

at risk for impaired skin integrity

related to:

urinary incontinence, personal care deficit (toileting), impaired verbal communication, hemorrhoids

patient will have analysis of data to maintain skin integrity and mucous membrane integrity. patient will receive optimal care with toileting and hygiene as evidence by inability to perform daily adl’s and self care deficit. goal will be met by 12-25-2008.

-note presence of compromised vision, hearing, speech that may impact self care as it relates to skin care

-evaluate client’s skin care practices and hygiene issues. incontinence may result in client’s skin care

-pay special to bony premises and other pressure points

-provide preventative skin care to incontinent patients. changing briefs frequently

-keep bed free of wrinkles, dry, use nonirritating materials.

-minimize contact with irritants (urine, stool)

-perform routine skin inspections, assessing color, temperature, texture and contours.

evaluation not possible because of amount of time with patient.

i understand that there is a lot that is missing, i was not able to copy everything...sorry

Daytonite, BSN, RN · Nov 22, 2008

if there is something you don't understand--ask. all my comments are in purple.

nursing diagnosis: disturbed sensory perception (visual, auditory)

related to: legal blindness secondary to glaucoma (if we know that glaucoma is the specific cause of the blindness you need to include here, in physiological terms, how it is causing the blindness. did you read about glaucoma and how it leads to blindness?

http://www.merck.com/mmpe/sec09/ch103/ch103a.htm

better: related to: optic nerve damage secondary to glaucoma

major: as evidence by: uses cane (this is a professional treatment/intervention for the problem)

requires assist in ambulation (this is a nursing intervention)

glasses, hearing aid (this is a professional treatment/intervention for the problem)

people who are "legally" blind still have some vision. it may only be that they can see light and blurs of movement, but you should describe that since that is part of the assessment of the patient's vision when you asked, "what are you able to see?" people with glaucoma have very blurred vision, see halos around lights and sometimes have nausea and vomiting from the constant blurring they see.

better: as evidence by: statement by patient that the only vision he/she has is moving blobs of colored light with bright halos around them.

complete on clinical day #3

care plan

nursing diagnosis

outcome / goals

nursing intervention

evaluation

nursing diagnosis:

disturbed sensory perception (visual, auditory)

related to:

glaucoma, legal blindness (change to: optic nerve damage secondary to glaucoma)

as evidenced by:

uses cane, requires assist in ambulation, glasses, hearing aid (needs to be changed to something like:statement by patient that the only vision he/she has is moving blobs of colored light with bright halos around them.)

the definition of this diagnosis is as follows: change in the amount of patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. (page 195, nanda-i nursing diagnoses: definitions & classification 2007-2008). what this means is that the patient is like mr. magoo and interprets the environment incorrectly as a result of their sensory misperception. in this case, because of the patient's blindness, what is happening? is the patient bumping into walls, stubbing their toe, tripping over furniture, walking out into the street when they think the light is green? these, by the way, could be aeb items for your diagnostic statement. i saw "encourage the use of hearing aid". is there an auditory problem here too? what's going on with orientation? that is not really a component of this problem--that is a part of dementia and belongs with another nursing diagnosis entirely.

patient receives optimal functioning (what is "optimal functional" for this person? spell it out.) within limits of visual impairments as evidenced by ability to care for self (spell it out--example: "will be able to pencil in eyebrows evenly", of course that also means that "gets eyebrows uneven because she can't see them clearly in a mirror" would be an aeb item of evidence, right?), to navigate environment safely (spell it out--example: "will successfully ambulate from point x to point y without bumping into anything," or something like that. again, this goes back to something that would have probably been picked up in the assessment and been part of the aeb evidence supporting this diagnosis.), and to engage in meaningful activities (i saw no interventions to assist the patient in engaging in activities). goal will be met by 12-25-2008.

-orient patient to environment (not appropriate to this diagnosis - disorientation was not one of the aeb items of evidence)

-make sure there are no changes to patients environment (changes as in, how? movement of objects? state that.)

-provide adequate lighting

-encourage use of hearing aid

-identify self when entering room and space

-build on patients remaining vision (i understand what you mean, but you have not identified what vision the patient has in the first place as part of the aeb evidence. what am i supposed to build?)

- orient to time, place, person, and surroundings (orienting to person and probably the time of day is not appropriate to this diagnosis because it has to do with disorientation which was not one of the aeb items of evidence and has to do with level of consciousness and not visual acuity)

- converse with and touch the client frequently during care if frequent touch is within the client's cultural norm

-keep call light button within reach (and tell patient where it is placed)

-pay close attention to patients emotional needs (how?)

- pay attention to background noise and reduce it to a minimum when attempting conversation (i would just say "keep background noise to a minimum to facilitate the patient's ability to focus on interpersonal communications")

-speak slowly and distinctly, use simple sentences

-lower pitch of voice and speak in tone that does not include shouting

evaluation not possible because of amount of time with patient.

-----------------------------------

nursing diagnosis: at risk for impaired skin integrity

related to: urinary incontinence, personal care deficit (toileting)

impaired verbal communication, hemorrhoids (since you don't want this to sound like it has been slanderous or copied, just say "external hemorrhoids and urinary incontinence due to difficulty communicating the need/and urgency to get to the bathroom".)

better: related to: urinary incontinence due to difficulty communicating the need/and urgency to get to the bathroom

care plan

nursing diagnosis

outcome / goals

nursing intervention

evaluation

nursing diagnosis:

at risk for impaired skin integrity

related to:

urinary incontinence, personal care deficit (toileting), impaired verbal communication, hemorrhoids (change to: external hemorrhoids and urinary incontinence due to difficulty communicating the need/and urgency to get to the bathroom)

patient will have analysis of data to maintain skin integrity and mucous membrane integrity.(sounds like a nursing intervention, not the result of an intervention which is what an outcome/goal is.) patient will receive optimal care with toileting and hygiene (define optimal care--spell it out) as evidence by inability to perform daily adl's and self care deficit. (this diagnosis is about prevention skin breakdown, not about the nursing staff's failure to assist the patient with adls and self-care which is what this sounds like. get the last half of this statement out of here because it sounds like you are trying to blame someone for the patient's problem.) goal will be met by 12-25-2008. (the outcomes/goals of "risk for" diagnoses are always that the problem, in this case, skin breakdown, doesn't happen. you can state that as "no skin breakdown", "no impaired skin" or break it down into the signs and symptoms of skin breakdown and piecemeal it out, i.e., "no skin redness" and stuff like that.)

-note presence of compromised vision, hearing, speech that may impact self care as it relates to skin care (i don't think this applies)

-evaluate client's skin care practices and hygiene issues. incontinence may result in client's skin care (you specified in the "related to" part of the diagnostic statement that urinary incontinence is the culprit here: evaluate client's hygiene following episodes of voiding. then, monitor the number of episodes of incontinence and whether patient is aware of the incontinence. maybe this patient needs to be on bladder training which nursing homes do all the time with incontinent patients who are partially incontinent and still do manage to be continent.

-pay special to bony premises and other pressure points (ok, i've paid special attention to them. what is "special attention"? spell it out--describe what you mean by "special attention".)

-provide preventative skin care to incontinent patients. changing briefs frequently (describe specifically what you mean by "preventative skin care". are you talking about washing with soap and water, using desitin ointment, vaseline intensive care lotion or something else? how frequently is "frequently"? only when the diaper is wet? how often is that? most facilities do minimal q2h checks.)

-keep bed free of wrinkles, dry, use nonirritating materials. (what are "nonirritating materials"? that's a new one on me.)

-minimize contact with irritants (urine, stool) (how?)

-perform routine skin inspections, assessing color, temperature, texture and contours. (when? every day? every shift? every time you feel like it?)

how are you going to help this person communicate the need to get to the bathroom or that they need to pee? that seemed to me to be what you were conveying as a risk factor: the patient is at risk for skin breakdown because they can't get to the bathroom so they pee and sit in it. is that right?

what are you doing about these hemorrhoids to prevent skin breakdown with them? i assume you want to do something about wiping after a bm that is going to avoid skin breakdown of the hemorrhoids if the stools haven't already caused a problem. how about using baby wipes such as huggies? i'm not sure what is in them, but a quick trip to the market and looking on the package will tell you what the ingredients are as well as the other brands on the market (i only know huggies because it is what i use for my cats). don't even go into diet and fiber because it doesn't belong here.

these websites have the signs and symptoms of stage i skin breakdown. you need those signs and symptoms to help you formulate your monitoring interventions and outcomes for this diagnosis:

http://www.hill-rom.com/usa/pdf/ctg285.pdf - guidelines for staging of pressure ulcers
http://www.medicaledu.com/staging.htm - staging of ulcers
http://ame-medical.com/staging_ulcers_guidelines.pdf - staging pressure ulcers
http://www.nursingquality.org/ndnqipressureulcertraining/module1/default.aspx - pressure ulcer training tutorial (includes photos)

see https://allnurses.com/forums/2751313-post8.html for some guidance on how to focus your interventions on these "risk for" diagnoses.

evaluation not possible because of amount of time with patient.