Care Plan Questions and HELP!! Please!!??

I did my first CP this semester on Pyloric Stenosis on a newborn. Even tho I did plenty of CP's in the Fall semester, I didn't do this one right!!

I got an 80% [which is passing] because she felt sorry for us!!

I had all the diagnostic labs for blood at the newborn levels and made up what the infant's would be if she actually had PS. She asked if the values were for adults!!

I only had 2 nursing diagnosis, on the reall baby and I should have had 5-6. On the PS CP, I had 6 Nursing interventions and 3 General Nursing care guidelines listed. I keep messing up the Goals.

For my goal for PS I put: Pt. will have no vomiting, by D/C. Pt. will meet body requirements within 3 weeks of d/c.

For the PES I put: High risk for dehydration R/T projectile vomiting.

Also, Altered Nutrition; less than body requirementsR/T projectile vomiting AEB: FTT.

My real pt. was healthy as a horse and so there was no reall CP needed, other than teaching.

Is there someplace on the web that teaches how to do care plans? I have Mosby's Nursing Care Plans, Nursing Diagnosis and Intervention. However, it is for M/S and not OB/NB PP GYN.

Any help would be greatly appreciated!!

[colleen10]

Hi there,

I don't have much experience in writing Diagnoses for Peds. but what did your instructor say was wrong with your Diagnoses and Goals?

At my school "Risk for Dehydration" would not be an acceptable Diagnosis and "vomitting" may not be completely acceptable either.

It would have to be writen as "Risk for Fluid Volume Deficit" r/t "forcing of the stomach contents up through the esophogus and out of the mouth".

I know and you know, we are saying the same thing, but my instructors want us to be as specific as possible to the physiological process that is occuring.

The only thing I can see wrong with your goals is that they may not be specific enough, no parameters for measuring them have been specified.

For example,

"will meet body requirements within 3 weeks of d/c"

You may want to put a specific date ie. February 17th, 2004, rather than "3 weeks after d/c". You may also want to write out the specific "body requirements" that are to be met by that day. ie. weight of 6lbs. 3 oz., length of 22 inches. etc. etc.

It sounds like you have the jist of what a Diagnosis and Care Plan are, you just need to tweek it a bit. My class had the same exact problem until our lab instructor sat down with us and really explained what we were to do.

What helped all of us, was our instructor all gave us the same fictional patient description. Then we each had to come up with 5 nursing diagnosis and care plan. Then we all met in class and went over what we all had. It made it a lot easier to see what was and wasn't acceptable and to see what other people can come up with despite it being the same fictional patient.

Maybe your classmates or instructor would be willing to do something like this.

Good luck with everything, I do think you are on the right path.

Col