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care plans

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by jbillado jbillado (New) New

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where can i find info. on maternity care plans?

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

6 Followers; 4 Articles; 20,908 Posts; 149,592 Profile Views

Hi! Welcome!

We are different here....we will help you find your answer to what you need but we need to know what your research has revealed to you first. What care plan resource do you use? All the information you need would be in the new version of the NANDA http://www.amazon.com/Nursing-Diagnoses-2015-17-Classification-International/dp/1118914937/ref=sr_1_1?ie=UTF8&qid=1417551211&sr=8-1&keywords=nanda+nursing+diagnosis

All care plans are all about patient assessment and what the patient needs right now. Tell me about your patient.

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I dont have time to wait for a book for this care plan. I did choose a premature birth with altered gas exchange, have goals and interventions.(its allowed to be fictitous). What if a goal is not met. Its a long term goal of clear lungs. Short term goal was met.

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5 Posts; 315 Profile Views

maternity is new for me. I have been an Lpn working in LTC. 5 clinical rotations to put it all together. Thats it.

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5 Posts; 315 Profile Views

your einsteen quote sounds like my study techniques. No one has any good advice on better study skills.

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

6 Followers; 4 Articles; 20,908 Posts; 149,592 Profile Views

I dont have time to wait for a book for this care plan. I did choose a premature birth with altered gas exchange, have goals and interventions.(its allowed to be fictitous). What if a goal is not met. Its a long term goal of clear lungs. Short term goal was met.
What care plan resource do you have? What semester are you? The is no way I can even help you as you have provided no assessment.

Care plans are all about the patient assessment. What the patient needs right now. Where they in the hospital? Are they living in long term care? Where did you meet the patient?

If this is an actual patient....what is your assessment? What were the vital signs? What did the patient complain of? Are the ambulatory? How are they at performing their ADL's?

Here is my normal speech.....You have fallen into the trick bag that many nursing students do....picking a diagnosis then trying to fit the patient into that diagnosis.

All care plans are based off of the patient assessment... Let the patient/patient assessment drive your diagnosis. Do 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.

What is your assessment? What are the vital signs? What is your patient saying?. 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? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to 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. 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.

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: ADPIE

  1. 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)
  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)

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.

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.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

A nursing diagnosis statement sounds like this.....from our GrnTea

"I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "
Now tell me about your patient

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5 Posts; 315 Profile Views

[TABLE=class: MsoNormalTable]

[TR]

[TD=width: 131] Nursing Diagnosis

[/TD]

[TD=width: 132] Expected Client Goal and Outcome Criteria

[/TD]

[TD=width: 132] Nursing Interventions

[/TD]

[TD=width: 132] Underlying Scientific Principle(s) of Nursing Interventions

[/TD]

[TD=width: 132] Evaluation

[/TD]

[/TR]

[TR]

[TD=width: 131] Impaired gas exchange r/t premature birth m/b Gestational age

[/TD]

[TD=width: 132] 1. Adequate gas exchange AEB PaO2 is 60-70 mm Hg, PaCO2 is 35-45 mm Hg

2. Maintain adequate body temp

3. Short-term goal: Decrease signs and symptoms of respiratory distress

4. Long term goal: No signs of respiratory distress AEB maintaining O2 sats >90% in room air with no grunting or retractions

[/TD]

[TD=width: 132] 1. Monitor vital signs, O2 Saturations, and arterial blood gases as ordered. Suction airway as indicated and administer oxygen prn per order

2. Monitor temp of baby and Isolette

3. ST-Administer corticosteroids per order

4.LT- Cluster nursing care, administer oxygen as needed, antibiotic treatment as ordered

[/TD]

[TD=width: 132] 1. To maintain adequate gas exchange and therapeutic blood gas levels

2. To maintain an adequate body temp.

3. ST-Reduced respiratory distress syndrome

4. To decrease oxygen demand and have no signs of respiratory distress

[/TD]

[TD=width: 132] 1. Goal met AEB O2 saturation s >90%, HR 120-160 bpm, arterial blood gases WNL, PaO2

is 60-70 mm Hg, PaCO2 is 35-45 mm Hg

2. Goal met. AEB Temp. at 36.5-37.5C

3. Goal met. Decreased signs and symptoms of respiratory distress AEB decreased retractions, grunting, nasal flaring or cyanosis

4. Goal not met AEB decreased but continued retractions, grunting, nasal flaring, cyanosis and rales auscultated in bilateral upper lobes

[/TD]

[/TR]

[/TABLE]

This is my care plan.

Reference

Durham, R., Chapman, L., Maternal-Newborn Nursing 2nd ed: the critical components of nursing care, 2014; F. A. Davis Company, Philadelphia, PA

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

6 Followers; 4 Articles; 20,908 Posts; 149,592 Profile Views

Great for the baby how about Mom?

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