Concepts in care plans and a rant

[LilPeanut, MSN, RN, NP]

Ok. Today was a very frustrating day for me - We had our first day on care plans. We had a 3 hour lecture then we were supposed to go back and write care plans in lab about 3 cases.

I'm just not thinking the right way yet and I wasn't able to communicate effectively to my teachers about my issues. I would try and give an example and they would get so hung up on the details of the example without answering the conceptual question behind it.

Ok. So, one of them was something like this:

Jane Smith has double above the knee amputations, is diabetic, obese and confined to a wheelchair. She is very active and often agitated. During her periods of agitation, she waves her arms around wildly and tends to sweat heavily. She has developed a 7cm x 3cm injury to her skin underneath one of her abdominal folds.

Now. I understand that the skin integrity is the most important thing. I really do. But out of all that, I see the (rather extreme) agitation as being very abnormal and potentially a huge contributing factor. Yes, treat the skin issue. But shouldn't the second priority be making sure she gets a psych eval or something?

I was just so frustrated when I was trying to talk with my instructors because none of them were understanding my train of thought and therefore couldn't help me redirect it to how it's supposed to be going. For me, it just doesn't work to say "this is the way we do it, now think like this." I have to understand what it is we're doing, why we're doing it etc.

This is my first quarter in my direct entry nursing program and my first big snag and it's kind of gotten me down. I don't think she meant to, but the way my clinical instructor responded to one of my questions/ideas really got to me - she basically just made me feel like I was the stupidest person alive. *sigh* Hopefully tomorrow goes better.

[stressgal, RN]

Sorry to hear your day was so frustrating. Care plans are a bear to wrap your mind around at first. Let us know if we can be of any help.

Remember to always prioritize everything with your ABC's then Maslow.

Have a better day tomorrow!

[maolin]

It's tough learning how to prioritize this stuff when there are so many things needing attention. Everything's important, right?

I have found that following the rules of prioritization are best for both NCLEX & care plans - ABC's first, then Maslow (physiological, safety, then psychosocial). The phsyiological concerns for this pt will come first - altered skin integrity. Then safety - risk for injury r/t agitated state perhaps, r/f infection. Then actually addressing the agitated state - Anxiety or whatever.

HTH.

[truern]

Peanut, tell me what you hope to accomplish with a Psych eval:p

Seriously, the patient already had both legs amputated (probably due to complications with her diabetes)...she's obese, sweats heavily, and already has a large area of skin breakdown.

After the skin integrity ND, I'd go with Ineffective Health Maintenance, Imbalanced Nutrition: more than body requirements, maybe some Noncompliance or Ineffective Mgmt of Therapeutic Regimen...heck, throw in some Risk for Infection and Risk for Injury while you're at it.

If you're really determined to delve into the Psych aspect, how about Chronic Low Self-Esteem or Disturbed Body Image??

Do you see the different ways to look at the whole picture now?:)

[LilPeanut, MSN, RN, NP]

Because it's not typical for someone, even who has had their legs amputated to be wildly agitated most of the day. This is what I'm not getting. I am viewing it as a mental health problem, which is just as physical to me as a ulcer. She could also be having an altered mental state because of something else.

I mean, if someone is schitzophrenic, you can do other things until the cows come home, but if you don't treat the schitzophrenia, they'll never actually get better.

I think what I'm having trouble with is adjusting to trying to only treat the symptoms, and ignoring the disease process behind it. Is that what I'm supposed to try and do??

[mitchsmom]

Because it's not typical for someone, even who has had their legs amputated to be wildly agitated most of the day. This is what I'm not getting. I am viewing it as a mental health problem, which is just as physical to me as a ulcer. She could also be having an altered mental state because of something else.

I mean, if someone is schitzophrenic, you can do other things until the cows come home, but if you don't treat the schitzophrenia, they'll never actually get better.

I think what I'm having trouble with is adjusting to trying to only treat the symptoms, and ignoring the disease process behind it. Is that what I'm supposed to try and do??

I totally understand what you are saying.

But, if she dies of an infection because of that skin breach, it won't matter what mental problem she has.

If you put the psych thing down at #2 or 3, that doesn't mean you are ignoring it, it just means the others are addressed first.

For example: A rape victim comes in the ER. Just because we fix her physical wounds first doesn't mean the ER staff is going to ignore her emotional wounds, right? It's just first things first.

At least that's what I think... I'm a student too so for whatever it's worth!!!

[LilPeanut, MSN, RN, NP]

I understand that part, that the skin integrity is the most important, but when I'm talking with my instructors, it's like the mental issues are almost an afterthought. And then I get frustrated because no one seems to get that I DO understand that the skin integrity is the most important thing and then just keeps harping on that.

I have a different outlook on it. I see that potentially the mental issue is the underlying cause of the skin issue, so you treat the skin issue while investigating the mental issue. Does anyone understand what I'm trying to say?

[truern]

LP, I think your instructors probably want you to focus on *nursing* concerns...sure, the doctor could order a Psych consult, but you, as the nurse doing this careplan, would look more at the things I mentioned before...some of which DO address the psych concerns but in ways that a nurse could intervene.

A nursing care plan is just that....a plan of nursing care.

Am I making more sense now? :)

[klone, MSN, RN]

Eh, I'm wildly agitated much of the time too. I'm relatively thin, have both legs and tend towards hypoglycemia.

I think you're reading too much into "agitation." Sounds like maybe she's just a high-strung person. Maybe she's Italian.

As others have said - you cannot diagnose her mental state. All you can do is diagnose her reactions to her mental state. That would be a "risk for injury" diagnosis.

[stressgal, RN]

I agree with the above poster. You cannot read anything into a case study or test question. This is one of the first things you learn. Deal with the facts. Maybe the client has an underlying mental disorder, but that is not the priority. Once again remember your ABC's and Maslow. This is how EVERYTHING is prioritized. I guarantee the possible other issues are not an afterthought, they are just attempting to get you to prioritize. You stated that this is your "first" day at care planning and I assure you the instructor is not trying to disrespect you by disagreeing with you. They are, more than likely, attempting to get you thinking critically as your tests and the NCLEX are set up.

[LilPeanut, MSN, RN, NP]

Oh, I know my instructors weren't trying to disrespect me or anything - it was a matter of not being able to communicate effectively and then frustration :)

I think I have a better idea now (I think!) I might try and find some exercises to practice with.

[stressgal, RN]

That's the attitude to have!

Let us know if we can be of any help!