Care plan

Daytonite, BSN, RN · Apr 16, 2008

a care plan is based on the information you collected about your patient's symptoms and responses to their cva and dementia. a care plan consists of identification of the patient's nursing problems and your strategies to solve them. to do that you first need to identify the problems. that begins by examining (assessing) the patient. a problem cannot be diagnosed without evidence to support it or back it up. so, you have to find evidence to support, or back up, any nursing problems (nursing diagnoses) this patient has.

unfortunately, i can't tell you what this patient's nursing problems are. you are the nurse who took care of her and assessed her. you observed what her physical deficits were as a result of her cva and what adls she needed assistance with. you saw how the dementia affected her behavior. i didn't. what you need to do now is think back over what these things were and get them written down so they can become part of the evidence to support problems for your care plan. to help you organize your thinking i strongly suggest that you read about cvas, their signs, symptoms and treatment. if you need help finding that information, you can find it on the websites listed on this thread: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites. i can only help pick nursing diagnoses when i have a list patient symptoms.

there is information on how to write a care plan on this sticky thread:

https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing discussion forum)

chevyv, BSN, RN · Apr 16, 2008

I'm a 3rd semester student and I found that if you can afford the expense, buy yourself a Nursing Care Plan book. They are really good resources for the beginner on up. I have 4 which is a bit overkill, but my instructor this semester required 2 collaborative care plans which were not covered in any of my other books. Check out Amazon and search Carpenito or Gulanic/Myers. Caprenito has a detailed collaborative section in the back that really helped me.

Do you have a good data collection tool? Our instructor gave us a big packet that covers all of the systems and you just take your info from the packet and plug it into your care plan sheet and go from there with your Analysis (Nsg DX) etc. Let me know if you need the packet and I'll try to post it. Good Luck :wink2:

apolojo11 · Apr 16, 2008

daytonite !! :lol2: yee

thank you so much .the web sites,the report and critical thinking sheet are really helpfull.keep up the good work.

thank you again. have a pleasant day!

a care plan is based on the information you collected about your patient's symptoms and responses to their cva and dementia. a care plan consists of identification of the patient's nursing problems and your strategies to solve them. to do that you first need to identify the problems. that begins by examining (assessing) the patient. a problem cannot be diagnosed without evidence to support it or back it up. so, you have to find evidence to support, or back up, any nursing problems (nursing diagnoses) this patient has.
unfortunately, i can't tell you what this patient's nursing problems are. you are the nurse who took care of her and assessed her. you observed what her physical deficits were as a result of her cva and what adls she needed assistance with. you saw how the dementia affected her behavior. i didn't. what you need to do now is think back over what these things were and get them written down so they can become part of the evidence to support problems for your care plan. to help you organize your thinking i strongly suggest that you read about cvas, their signs, symptoms and treatment. if you need help finding that information, you can find it on the websites listed on this thread: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites. i can only help pick nursing diagnoses when i have a list patient symptoms.
there is information on how to write a care plan on this sticky thread:
https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing discussion forum)

apolojo11 · Apr 16, 2008

Chevyv

Thank you Very much for your advise.Please post the Packet.that will be very helpful to me thank you again .

Have agreat day

Apolojo

classicdame, MSN, EdD · Apr 16, 2008

what are the real and potential probems this patient has that YOU can address? What interventions can you do to address those problems?

chevyv, BSN, RN · Apr 17, 2008

I'm going to attempt to post the packet. I don't see a way to attach it, so I'll try to post. I hope this helps

Care Plan Documentation

Subjective/Objective Data Collection Tool

Categorized by Dimension

DIMENSION

SUBJECTIVE

OBJECTIVE

Respiration

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes”

History of respiratory problems

dyspnea

cough/sputum

smoker

Rate:

Rhythm:

Cyanosis:

Clubbing:

Breath sounds:

Inspiratory:

Clear
Crackles – fine or coorifice
Wheezing
Lung field

Expiratory:

Clear
Crackles – fine or coorifice
Wheezing
Lung field

Cough:

Productive

Sputum – color, amount, consistency

Nonproductive

Oxygen: Rate:

Nasal cannula

Mask

Labs

Medications

Other:

Respiration

Analysis (problem, need,

potential problem/need)

DIMENSION

SUBJECTIVE

OBJECTIVE

Circulation

Data from client’s point of view

-feelings

-perceptions

-concerns

This is in “quotes”

History of:

Hypertension
Heart problems

Circulation problems

Verbalizes:

Chest pain
SOB
Pain with ambulation

BP: (arm)

Apical:

Rhythm:

Other pulses:

Lips: (color)

Mucous membranes:

Jugular venous distension:

Nailbeds:

Capillary refill time:

Edema

Labs

Medications

Other:

Circulation

Analysis (problem, need,

potential problem/need)

Food/Fluid

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes”

History of GI problems:

History of diabetes or thyroid problems:

Appetite:

Recent weight change:

Knowledge of diet:

Current GI complaints:

Current diet:

Weight
Height
Intake

Increased hunger/thirst

Excessive sweating/urination

Edema:

Hands
Feet
Generalized

Condition of teeth:

Dentures/partial/crown
General appearance

Labs

Medications

Other:

Food/Fluid

Analysis (problem, need,

potential problem/need)

DIMENSION

SUBJECTIVE

OBJECTIVE

Pain/Comfort

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes”

History of pain

Complaints of pain:

onset
location
duration
description
precipitating factors
severity (scale 0-10)

Response to pharmacological and non-pharmacological measures to control pain

Nonverbal responses:

Guarding:

Labs

Medication usage:

Other:

Pain/Comfort

Analysis (problem, need,

potential problem/need)

Activity/Rest/

MusculoSkeletal System

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes”

Occupation:

Hobbies:

Interests:

Restful sleep:

naps
night

Sleep aids

Exercise/Activity level

active
sedentary
tolerance
restrictions
problems with fatigue

Activity level:

Number of assists:

Assistive devices:

gait belt
cane/walker
wheelchair

Range of motion

Active/passive
Extremity/repetitions

Muscle strength/resistance

Ambulation:

Steady
Unsteady

Labs

Medications

Other:

Activity/Rest

Analysis (problem, need,

potential problem/need)

DIMENSION

SUBJECTIVE

OBJECTIVE

Safety/Skin

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes

Allergies:

History of:

compromised immune system
falls

Environmental concerns:

visual disturbance
hearing impairment
altered mobility

STDs

Alarm:

bed/chair
jacket/belt
sitter

Use of side rails/other devices

Temperature

Heat/cold intolerances

Medication usage:

Skin assessment:

color, temp, moisture
reddened area
noted breakdown

Labs

Medications

Other:

incisions/drains/dressing
invasive lines/tubes

Safety

Analysis (problem, need,

potential problem/need)

Neurosensory

Data from client’s point of view

-feelings

-perceptions

-concerns

This is in “quotes”

History of:

headaches
fainting
vertigo
seizures
tingling/numbness

Hearing:

Vision

Mental status:

Person
Place
Time

Speech:

PERRLA:

Bulging eyes:

Presence of red reflex:

Ability to follow commands:

Strength equal bilaterally:

Other:

Glasses
Contacts
Hearing aid

Labs

Medications

Neurosensory

Analysis (problem, need,

potential problem/need)

DIMENSION

SUBJECTIVE

OBJECTIVE

Elimination

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes”

Variation from normal patterns:

History of bowel problems:

Diarrhea
Constipation
Other

History of urinary problems:

Urgency
Frequency
Dribbling
Nocturia
Other

Date of last BM

Continent

stool description
size, consistency, color, odor

Incontinent

toileting schedule
bowel program
devices/products used

Urine

Continent

urine output
urine description
color, clarity, odor

Incontinent

toileting schedule
devices/products used

Abdominal assessment

bowel sounds

flatus

Labs

Medications

Other:

Elimination

Analysis (problem, need,

potential problem/need)

Hygiene

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes”

Perceived need for help from others to do ADLs

toileting
dressing/grooming
feeding
bathing/hygiene

Assistance required:

set-up
partial
bed bath/complete
tub/shower

Equipment needed:

Labs

Medications

Other:

Hygiene

Analysis (problem, need,

potential problem/need)

DIMENSION

SUBJECTIVE

OBJECTIVE

Ego Integrity

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes”

Developmental stage:

Current stressors:

Coping methods:

Religion:

Use of community resources:

Other

Emotional status:

Affect
Eye contact
Non-verbal behaviors
Withdrawn
Anxious

Labs

Medications

Other:

Ego Integrity

Analysis (problem, need,

potential problem/need)

DIMENSION

SUBJECTIVE

OBJECTIVE

Sexuality/Reproduction

Data from client’s point of view.

-feelings

-perceptions

-concerns

Student nurses asks, “Has your health problem interfered with your sexuality?”

This is in “quotes”

History of surgeries, infection or diseases for women or men that would interfere with sexual expression, conception or child-bearing

(breast, menstrual, ovarian, prostate, endometrial problems; sexually transmitted infections ; mobility problems that interfere with sexual expression)

Sexuality/Reproduction

Analysis (problem, need,

potential problem/need)

DIMENSION

SUBJECTIVE

OBJECTIVE

Social Interaction

It posted a little differently than the packet. If you can't make heads or tails out of this, pm me and I'll send it to you that way. Its approx. 10 pages to print.

Data from client’s point of view.

-feelings

-perceptions

-concerns

This is in “quotes”

Cultural perspectives:

Family structure:

Role in family:

Support person:

Community resources/support:

Speech:

Quiet
Talkative
Eye contact

Participation in activity

Health care providers
Visitors
Outside activities

Labs

Medications

Other:

Social Interaction

Analysis (problem, need,

potential problem/need)

2/19/08 PEH