Care Plans

[lschroederm1]

Soo I need your help guys! I have a picky instructor who keeps tearing apart my care plans. I have no trouble with the assessment part and figuring out the diagnosis but her thing is that we need to have 2 outcomes with 4 interventions related to how you will achieve that outcome (which is NOT as easy as it may sound)!

Here is my issue. My patient had an arthroscopy to fix a rotator cuff injury. She is relatively young with no other major problems. We discussed that impaired skin integrity is a problem, as well as risk for infection and impaired comfort. She does not allow us to do risk for as a diagnosis if our patient's have active problems so this is what I've got. I do realize impaired skin integrity may not be the best choice, but I discussed it with my instructor so I'm going for it. Please help me out!

Also, my patient was discharged during my shift today but I still did implement teaching because she lives alone and will need to change her dressing in 2 days.

Diagnosis: Impaired Skin Integrity r/t arthroscopy AMB a foam tape dressing

Outcomes: (1) Pt will verbalize importance of good skin integrity by discharge date

• SN will educate pt on importance of eating a well-balanced diet to support wound healing.
  
• Pt will describe need for hydration so the wound receives proper oxygen and nutrients to heal.
  
• SN will educate patient on keeping skin clean and dry
  
• 
  

(2) Pt will maintain skin integrity during hospital stay.

• Pt will be assisted to reposition every 2 hours.
  
• SN will monitor the condition of the skin at least once a shift to assess for erythema, edema, and drainage
  
• 
  
• 
  

Feel free to tear this one apart and give me any feedback! I need a couple more nursing interventions without sounding too repetitive.

[KrCmommy522, BSN, RN]

How about the pt will demonstrate a dressing change by time of discharge? Pt will be able to state S/S of infection to monitor for by time of discharge. I wouldn't put r/t arthroscopy. I would probably put r/t incision from arthroscopy or just r/t surgical incision. I wouldn't use AMB foam dressing - That is not why there is impaired skin integrity - What is UNDER the foam dressing? What did you assess when changing the dressing? (e.g., AMB 1-inch surgical incision, what kind of drainage if any, how much blood.

Do you have a nursing diagnosis book? They are VERY useful when doing care plans - coming up with interventions and outcomes. I never had a problem coming up with them when I used my nursing diagnosis book (my instructors actually said I would put too MANY down). I used Ackley's Nursing Diagnosis Handbook. It is a wonderful book. One part has where you can look up based on the pts medical diagnosis and you can see what possible nursing diagnoses MIGHT go with that medical diagnosis (of course, you have to use your ASSESSMENT to drive the nursing diagnosis - not the medical diagnosis or whatever you have in your mind already). You don't want to make the pt and assessment fit the nursing diagnosis that you have in mind. You want the pt and assessment to drive the diagnosis.

[lschroederm1]

Thanks so much KrCmommy522! This was very helpful and I made changes accordingly! I do have a NANDA book and mine is Ackley as well. I try to steer away from using that book because I tend to write exactly what their interventions and outcomes are and my care plan doesn't end up being individualized. "You want the pt and assessment to drive the diagnosis."

I am definitely going to apply this moving forward. Thank you for your kind words and input.

[KrCmommy522, BSN, RN]

Thanks so much KrCmommy522! This was very helpful and I made changes accordingly! I do have a NANDA book and mine is Ackley as well. I try to steer away from using that book because I tend to write exactly what their interventions and outcomes are and my care plan doesn't end up being individualized. "You want the pt and assessment to drive the diagnosis."

I am definitely going to apply this moving forward. Thank you for your kind words and input.

Glad I could help. I understand you wanting to steer clear from using the book so you don't write exactly their interventions and outcomes. However, it helps to give you ideas, and then you can use that to individualize it towards your pt. I never wrote them exactly, but they were always extremely helpful in giving me ideas to come up with something that would work for my pt - something individualized for that specific pt. So, if you are ever stuck, it might be helpful to see what the book gives for interventions and outcomes, and that might give you an idea of something that you can use that would work for your pt.