Critique My First Care Plan

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Hi, I am in my first semester of nursing school and am about to finish my first care plan. There are a few things I am confused on:

  • How to make my outcomes and monitoring interventions measurable.
  • Is it ok for my teaching interventions to be family focused on this specific care plan. I know usually it is to teach the patient something specific pertaining to their nursing diagnosis.
  • Is my subjective data ok?

Any help would be appreciated ;) attached is my rough draft, formatting may be off. Thank You

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[TD=colspan: 3]NURSING PROCESS EXAMPLE

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[TD]Client Initials:

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[TD]Student:

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[TD]Based on Assessment Data

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[TD]Date:

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[TD=colspan: 3]Plan

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[TD]Nursing Diagnosis

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[TD]Goals and Outcomes

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[TD]Nursing Interventions

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[TD]Rationale

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[TD]Evaluation/Modification

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[TD]Problem:

Chronic Confusion

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[TD]Goal (Date and Time frame):

Client will function at maximum cognitive level by end of shift 10/3/13, 1500.

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[TD]Monitoring Interventions:

  1. Determine the client's cognitive level using the Montreal Cognitive Assessment to develop a baseline.
  2. Promote routines and facilitate success by keeping frequently used items in consistent, visible locations.
  3. Determine client's normal routines and attempt to maintain them.

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[TD]Author/Page #/ Other sources

  1. To have a baseline for comparison.

Ackley & Ladwig

pg. 231

  1. Practicing routines in an unchanged environment will assist the client in successful maintenance and performance of skills.

Ackley & Ladwig

pg. 232

  1. Activities designed to be consistent with clients past routines are effective at enhancing quality of life.

Ackley & Ladwig

Pg. 232

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[TD]Interventions:

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[TD]Etiology/Related to:

Progressive cognitive impairment related to vascular dementia uncomplicated.

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[TD]Symptomatology/Defining characteristics/ As Evidence By (AEB)-

Subjective Data:

Unable to obtain any information from the client.

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[TD]Outcome Criteria (AEB):

Maintain as much of client's normal routines as possible.

Client will have an environment structured for maximum functioning.

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[TD]Therapeutic Interventions:

  1. Nurse will provide structured social and physical activities individualized for client q shift.
  2. Use cues such as picture boards, denoting day time and location to help with orientation prn.
  3. Provide calm environment, eliminate extraneous noise/stimuli qd.

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  1. Structured activities result in an improvement in disruptive behavior.

Ackley & Ladwig

Pg. 233

  1. Reality orientation can help some clients remain orientated.

Ackley & Ladwig

Pg. 233

  1. To reduce agitation.

Ackley & Ladwig

Pg. 232

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[TD]Goal(s)

Client will function at maximum cognitive level by end of shift 10/3/13, 1500.

Met/Progressing/Not Met:

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[TD]AEB:

Progressive cognitive impairment

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[TD]Objective Data:

Impaired long term memory. Impaired short term memory. Only orientated to self.

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[TD]Teaching Interventions:

  1. Teach family how to converse with memory impaired person.
  2. Recommend family develop memory aid wallet or booklet that contains pictures that chronicle the client's life.
  3. Teach family what to expect with the dementia process.

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  1. Helps family communicate at well as manage difficult behaviors.

Ackley & Ladwig

Pg. 236

  1. Using visual aids decreases the number of confused statements and helps client make more factual statements.

Ackley & Ladwig

Pg. 236

  1. Reduces family distress regarding decision making throughout the course of dementia.

Ackley & Ladwig

Pg. 236

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[TD]Modifications:

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[TD]Revise/Continue/Resolve

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Up Vote Up Vote ×

Your goal needs to be measurable: You wrote"

Client will function at maximum cognitive level by end of shift 10/3/13, 1500."

What is maximum??? " - you can't measure that. your outcome;"(AEB):

Maintain as much of client’s normal routines as possible. what is normal ??? It needs specificity. If I was your relief nurse, and I was reading your AEB, i would have a different interpretation of "normal". You must give specifics. For example; Client will be orientated to person, place and time on my shift,... then, what would you add for AEB? Your off to a good start! Just be specific! Laura RN

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Specializes in Oncology.

The nice thing about real life nursing- your care plans are check lists in the computer. Some measureable goals might be distance walked, transferring safely to commode, drinking at least 2 Ensures a day, not falling, remaining free of pressure ulcers, getting 2000 mls of better on incentive spirometry, participating with OT, being out of bed a certain amount of time, drinking a certain amount of fluid, etc. Good luck!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

moved to nursing student assistance for best response

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Thank you. I was feeling like I couldn't put those things because they aren't realistic. My patient will not be orientated to place and time, if that makes sense. Is there ever an exception to the fact hat it has to be measurable, or is that always a sure thing? Thanks again

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