care plan

[sammy62]

First question -Is a nursing process the same as a nursing care plan?

Second question- If a client was having an appendectomy and has diabetes what kind of precautions need to be taken?

thanks

[fasolagrrl]

Oh, sort of. The nursing process is what nurses DO: assess, diagnose, plan, intervene, evaluate (ADPIE).

A care plan describes the process. This year we are using the SOAP format, which I quite like. S for subjective, O for objective, A for assessment, and P for plan. There's an extension to this with an I for intervention and E for evaluation. So, it then becomes a SOAPIE.

S: (what the patient says) "My finger hurts."

O: (what you observe) Splinter in finger

A: (nursing diagnosis) Risk for infection

P: (what you'll do to fix the problem) Remove splinter, apply antibacterial ointment as ordered, teach patient how to recognize signs of infection

Those are kind of lame but I'm getting ready to go to bed and I think they illustrate the point.

[Daytonite, BSN, RN]

a nursing care plan is the written documentation of the nursing process. the nursing process is nothing more than a problem solving method that we use. you follow the same steps to write a care plan that you follow to perform the nursing process:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

if a client was having an appendectomy and has diabetes what kind of precautions need to be taken?

what you need to do is look up information on an appendectomy (http://www.surgeryencyclopedia.com/index.html) and diabetes, particularly complications. you also need to know what happens during general anesthesia and the possible complications

• breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  
• hypotension (shock, hemorrhage)
  
• thrombophlebitis in the lower extremity
  
• elevated or depressed temperature
  
• any number of problems with the incision/wound (dehiscence, evisceration, infection)
  
• fluid and electrolyte imbalances
  
• urinary retention
  
• constipation
  
• surgical pain
  
• nausea/vomiting (paralytic ileus)
  

and how it might have an affect on someone with diabetes (i.e., patient is generally npo for 9 hours before surgery. how does that affect his diabetic condition? if the patient has circulatory problems to the lower extremities as a result of their diabetes, how does that affect surgical care if the patient is lying still for a long length of time?). you have to look at these connections.