Care plan shame

classicdame, MSN, EdD · May 21, 2012

how do they breathe? How do they eat? How do they eliminate waste? Is there any touching going on (massage)? How do they communicate pain? If they are not vegetative, how do they communicate period?

Look at their meds. That should give you a clue as to what needs to be monitored (BP, glucose, fluid intake/output)

Double-Helix, BSN, RN · May 21, 2012

It sounds like the problem is that you have admitted that your assessment in incomplete. In order to write a through, accurate care plan, you HAVE to have an in-depth assessment. If you are forgetting things then you need to create a list to bring with you when you do your assessment. This list should have all the components of an objective head to toe assessment and a subjective assessment (psychosocial) and you should check them off as you complete each step. Do your assessments this way until it becomes second nature. It's imperative that you learn how to do a complete and accurate assessment in order to be a competent nurse.

Once you have a complete assessment, you will find it easier to come up with diagnoses that will fit your patient- and you'll find it easier to write a decent care plan.

psu_213, BSN, RN · May 21, 2012

As was previously mentioned...have a list. Neuro: LOC, pupil size, are facial movement symmetrical, ability follows commands, etc. Respiratory: Breath sounds, bilateral chest expansion, use of accessory muscles, etc. Don't necessarily pull the list out when you are first assessing the pt. After you assessment, leave the room and go right down the list and come back in to assess what you missed on your list.

P.S. Don't feel shame; care plans are difficulty. With hard work, you will get it.

Esme12, ASN, BSN, RN · May 21, 2012

Welcome to an! the largest online nursing community!

OK...first......let the patient drive your diagnosis, not try to fit the patient to the diagnosis you found first. you need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis. get a good care plan book to help you.

Maybe you need a brain sheet to help you organize your information and assessment.

FinalGraduateShiftReport.doc

DAY SHEET 2 doc.doc

I made some for nursing students and some other an members have made these for others.....adapt them way you want. I hope they help.

What is your assessment? Is the the patient having pain? Are they having difficulty with adls? What teaching do they need? What does the patient need? What is the most important to them now? How is their breathing? What is their nutritional status? What are the bowel sounds. Even vegetative patients have problems.

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.

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.

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.

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. There are currently 188 nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. What you need to do is 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.

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:

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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. At all times. And that is within the spirit of step #1 of this whole 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. 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.

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.

Care plan reality: Is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every NANDA nursing diagnosis has a definition).

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.

knighton201 · May 22, 2012

What i had to do for my first few assessments is take the sheet i had to turn in and do it at bedside, so if you miss anything, patient is right there for you to reassess so you don't forget anything, eventually (and hopefully your turn in sheet is written in some order like this) you'll want to develop a system and order to how you assess, so you practice it the same way each time and it becomes a habit which order you assess, we learned head to toe at my school.

so as a student I would:

check pupils, cranial nerve check, inside the mouth, heart/lung sounds, bowel sounds then palpation (never palpation first), Genitary/Urine via foley/bedside comode/urinal or interview patient (unless you were lucky enough to catch them before they flush or get them to call ya before flushing), UE strength check, peripheral pulses UE & cap refil, lower peripheral pulses & cap refil, LE strength test, all while checking for skin integrity and anything else irregular. For purposes of convenience on my patient, the one facility had strict 2hr turns for all bed rest patients, and I'd follow the two PCT's during their next 2hr turn schedule when they did my patients area of the hall to check back for skin integrity (usually had big boys/girls that weren't easy to one man roll)

as the others said above, without a good assessment you cannot get a good care plan going, cause you won't know what patient needs you as the nurse will need to fulfill, and hope this helps for a basic head to toe

*disclaimer new grad so still looking to refine my assessment skills into a more effecient methods, constructive criticism welcome*

Care plan shame

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