Critique Care Plan Please!

[ndh_cna_studentRN]

this is the first care plan i've had to do. i am looking for some advice and suggestions to make this an a+ care plan. if we get below an 80% we get kicked out of the program so it's very important that i get a good grade. i have spent (probably) a total of 8-10 working on this assignment so i'm not asking for anyone to do my homework for me. any help will be greatly appreciated!!! (my clinical instructor suggested that i use ineffective tissue perfusion and my priority nursing dianosis, based on abcs)

[color=gray]pt info:

[color=#808080]admitted with acute diverticulitis. futher testing showed a perforated bowel. pt was taken to surgery and a sigmoid colon resection with temp colostomy placement was performed. (post-op day 1) loc= x2 (anesthesia has made pt confused). hx of lung ca (recent chemo), copd, asthma, iddm, anxiety disorder.

maslow: physiology

erickson: integrity versus despair

p. ineffective tissue perfusion

e. r/t anemia and lung disease

s. as evidence by abnormal lab results (h&h 9.1 and 27), the need for supplemental oxygen, the physician's order for prbc transfusion, and hx of small cell lung ca, copd, asthma, and dm.

outcome: pt will have normal h&h lab results, be weaned from supplemental oxygen, and have an oxygen saturation >90% on ra prior to discharge.

interventions:

1) transfuse packed red blood cells to pt as ordered by physician. (collaborative)

2) monitor pts hemoglobin and hematocrit lab values qdaily. (collaborative)

3) monitor pts v/s (o2 sat, b/p, p, t, r) q4h and document. notify physician if significant deviation from baseline occurs.

4) administer oxygen to pt as ordered (3l via nc). (collaborative)

5) assess pts lung sounds qshift and prn and document. notify physician if significant deviation for baseline occurs.

6) monitor pts skin temperature and color to assess peripheral perfusion qshift and prn.

7) discuss diagnosis, current and planned therapies, and expected out comes with pt. provide information on normal tissue perfusion and possible causes for impairment. evaluate the pts knowledge of possible causes of impairment by asking the pt to list signs and symptoms that should be reported to the physician. this will be done once the effects of anesthesia have worn off.

rationales:

1) page 1021 (p&p) "the objectives for blood transfusions include (1) increasing circulating blood volume after surgery, trauma or hemorrhage; (2) increasing the number of rbcs and maintaining hemoglobin levels in clients with severe anemia; and (3) providing selected cellular components as replacement therapy (e.g., clotting factors, platelets, albumin)." page 912 (p&p) hemoglobin carries the majority of oxygen to tissues. anemia decreases the oxygen-carrying capacity of the blood.

2) page 300-301 (pagana) decreased levels of hgb and hct indicate anemia. decisions concerning the need for blood transfusion are usually based on the hgb or the hct. in an older individual with an already compromised oxygen-carrying capacity, transfusion may be recommended when the hgb level is below 10 and the hct level is less than 30%.

3) page 503 (p&p) as indicators of health status, these measures indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions. measurement of vital signs provides data to determine a client's usual state of health (baseline data). a change in vital signs indicates a change in physiological function. assessment of vital signs provides data to identify nursing diagnoses, to implement planned interventions, and to evaluate outcomes of care. vital signs are a quick and efficient way of monitoring a client's condition or identifying problems and evaluating the client's response to intervention.

4) page 951 (p&p)" oxygen therapy is cheap, widely available, and used in a variety of settings to relieve or prevent tissue hypoxia (thomson and others, 2002). the goal of oxygen therapy is to prevent or relieve hypoxia. oxygen is not a substitute for other treatment, however, and is used only when indicated. oxygen is a medication. as with any other medication, the dosage or concentration of oxygen is continuously monitored. routinely check the physician's orders to verify that the client is receiving the prescribed oxygen concentration."

5) page 561 (iggy) provides information about the flow of air through the tracheobronchial tree and helps identify fluid, mucus, or obstruction in the respiratory system.

6) page 607 (p&p) the condition of the skin, mucosa, and nail beds offers useful data about the status of circulatory blood flow.

7) increased knowledge leads to a change in attitude that in turn affects behavior. (http://www.ncbi.nlm.nih.gov/pmc/articles/pmc227189)

[Sanuk]

I can't respond to the formatting, only the content since I don't know what instructions your professors have given you. I have a few comments: you may not be able to get his sats up above 90% depending on how severe his COPD is, whether he's had a pneumonectomy, etc. It might be better to state that he will be back to his pre-op level. Next, when you're assessing peripheral perfusion, cap refill needs to be on the list. I think you've done a great job if this is your first care plan!

[nurseprnRN, BSN, RN]

i would also like to point out that according to the ana standards and scope of practice, nurses are legally obligated to implement the medical plan of care. the nursing plan of care, while it may be collaborative with other disciplines, is not dependent on them. therefore, if you find yourself writing something like, "do xyz as ordered," that's not collaborative, that's implementing an aspect of the medical plan of care. we have to do that, but it's assumed, and imnsho does not belong in a nursing plan of care.

this distinction is sometimes difficult for students, because they see nursing so often in terms of performing tasks, aeb their focus on lab checkoffs, "ooh, you got to do an xyz!!" and the common new grad lament, "i feel so inadequate, i never did an xyz as a student!"

nursing is a scientifically-based discipline with its own bases for practice. as a demonstration, let's consider this: what's the difference between a medical plan of assessment and care for pneumonia (since it is an easy thing to consider) and the nursing plan of assessment and care for pneumonia?

sure, when the physician or nurse practitioner makes a medical diagnosis of pneumonia, the medical plan of care will likely be based on lung sounds, cultures, diagnostic imaging, sats, and the like, and include things like oxygen and antibiotics and periodic imaging (x-ray) to see how things are progressing.

nowhere is it written that nursing assessment does not and cannot include knowing the results of all those tests and exams-- that's where the collaboration comes in. in addition, when i am assessing a person with pneumonia, i'm looking for nursing assessment bases of my nursing plan of care-- my nursing treatment plan.

if she's sob when i watch as she does adls, i'm going to be thinking of clever ways to decrease exertion (fatigue, impaired physical mobility, ineffective breathing pattern, activity intolerance, self-care deficit).

if she's hypoxic or hypercapneic (impaired gas exchange), i'm looking at the effects of those on other body systems, like mentation (impaired memory, anxiety), digestion, risk for pressure ulcers (risk for injury), and decreased healing of (whatever injury or surgery she had).

if she's been told she has to stop smoking, but she doesn't think she can or that it won't matter anyway, that's gonna prompt me to assess and treat for hopelessness: subjective state in which an individual see limited or no alternatives or personal choices available and is unable to mobilize energy on his own behalf, and powerlessness: perception that one’s own action will not significantly affect an outcome; perceived lack of control over current situation or immediate happening.

if her sob and resultant disability is bad enough, i might see caregiver role strain, and look to see what i can set up to help with that.

sure, you say, this is all "common sense." well, if it were more common, we'd all be better off. but a lot of this is not in the medical plan of care. these sorts of things are purely in the nursing realm; they are not part of the medical plan of care. when you learn nursing, you show your understanding by writing a nursing plan of care, not just indicating that you intend to follow the law and implement the medical one.