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Discussion

Care plan ideas to implement <4 h

I basically understand the ideas behind concept maps, dx, etc. (basic = 1st semester student). My frustration is choosing goals and interventions that can be completed within the 4 hour clinical experience. I am not to choose interventions that might roll into another clinical day. My interventions must be supported by the text only. (kozier & Erbs fundamentals 8th edition.).

My clients are geriatric long term care residents. Majority with dementia so assessment is sometimes difficult, and education doesn't seem appropriate. We have been told not to use chronic confusion dx as there is nothing we can do. Skin care problems are also discouraged so they will not be overused.

I'm looking for explanation on how to approach this. I feel as though Im hog tied before I begin and my frustration is making me blind to the possibilities.

Help!

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    • Featured Replies

    my instructor explained to me, you don't always have to use the primary diagnosis. doing the care planning is to show your understanding of the nursing process. perhaps choose one of their other diagnoses (usually there are many to choose from). things like constipation, pain, impaired mobility, or risk of falls are easy. you should have a nursing diagnosis book that is required. (the one at my school is ackley, but our instructors will accept any diagnosis book reference) using the diagnosis book is the easiest. you look up the medical diagnosis in the front, and there is a list of many nursing diagnoses that are appropriate for that medical diagnosis. you then can look those diagnoses up in the back and there is many interventions with rationale. then you can just page through and find applicable ones that you could use for a short time frame. i think it does sound hard to have a goal you can evaluate in 4 hours. usually we would make care plans, and then evaluate the following week. hope this helps. good luck! :)

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    • Experts

    I personally love the "remain free"

    Pt will remain free of falls/avoidable injury.

    Pt will have no incidents of aspiration.

    Pt will verbalized satisfaction with ______

    Pt will consume adequate________

    Pt will use call light _____________

    Pt will verbalize pain level at or below agreed pain goal.

    Etc etc etc.

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    • Experts

    With dementia consider risk for aspiration or impaired swallowing (obviously only if it actually exists as a problem). Also, sometimes there are behaviors that need managed shift by shift. Fall risk can be high (or risk for other injuries).

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    resident will consume 8 oz of water by 3pm

    resident will consume 75% of lunch by 1 pm

    resident will remain free of injury during my shift

    resident will participate in one activity today

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    • Author

    Thank you so much for your ideas. My mind was so focused on the limited time frame, I forgot there are still several things I can do and assess.

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    If any have acute pain, you could do nonpharm interventions like massage or guided imagery, too.

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