Care plan


Where is a good place to ask care plan questions. If this is the right place...then here I go...otherwise direct me please!

I had a rotation in OR today and my instructor wants me to focus on the spinal anesthesia the patient receive for my care plan. She suggested I do peripheral neurovascular dysfunction, but I am at a loss here for NI. Does anyone have any other ideas for nursing dx or how I shold go about this. I am soooo frustrated:crying2: TIA

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

we answer care plan questions and help students with care plans on the student forums. care planning is determining the patient's nursing problems and designing strategies (nursing interventions) for them. i help students with their care plans all the time, but you need to post more information about the patient and your assessment of them. diagnosis is based on the symptoms the patient has. interventions are based upon those same symptoms.

what your instructor is getting at is that there are complications of spinal anesthesia and she wants you to focus on peripheral neurovascular dysfunction. because you didn't post any other information about your patient i can't give you much more specific help except that i can tell you that the complications of spinal anesthesia are:

  • hypotension
  • rash around the epidural injection site
  • nausea and vomiting from the opiates administered
  • pruritis of the face and neck caused by some epidural narcotics
  • respiratory depression up to 24 hours after the epidural
  • cerebrospinal fluid leakage and spinal headache from accidental dural puncture
  • sensory problems in the lower extremities

i recommend that students follow the 5 steps of the nursing process when care planning:

  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)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]how to write goal statements:

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

there is a thread on the student forums where you can see questions on how to write care plans have been answered:

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