First Care Plan! Any obvious mistakes? THANKS!

Daytonite, BSN, RN · Nov 3, 2009

perform assessment : ??

assessment is step #1 of the nursing process. assessment is done to find as much abnormal data about the patient as possible. the second step of the nursing process, diagnosis, cannot be done without knowing this information. i have no idea how you rationalized and determined the 4 nursing diagnoses that you did come up with.

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nursing diagnosis: expected outcome:

impaired walking d/t r leg contractured amb pt unable to walk

definition: limitation of independent movement within the environment on foot.
your aeb evidence should be the patient's impaired ability to walk in all kinds of different situations (distances, stairs, manage little bumps and uneven surfaces, inclines. endurance, steadiness, keep their balance). that is what this diagnosis is about.

expected outcome:

the pt. will exhibit increased physical mobility as evidenced by ambulating, with walker, 30 ft. in hallway by 01/01/09

outcomes need to include 4 elements:

the behavior you want the patient to perform (ambulate using a walker)'
be measurable (30 feet)
sets the conditions under which the behavior should occur such as when and how frequently (ex: how many times a day)
a realistic time frame by which it must be completed (by 1/1/09)

it is not necessary to include such remarks as "

pt. will exhibit increased physical mobility

" since this diagnosis is not about physical mobility, but about

impaired walking

.

intervention: : intervention rational:

1. rom's to ble's :1. promotes flexibility

2. sleep with r leg extended: 2. ??

i don't get how sleeping with the right leg extended helps the patient walk.

3. explain importance of physical therapy: 3. provide education

4. ?? 4. ??

your interventions are for contractures. your interventions need to help them improve their walking ability so they can navigate distance, inclines, stairs or whatever they were having problems with which is why you diagnosed a walking problem in the first place (hard to know because the only evidence you list is

unable to walk

). if this patient absolutely can't walk at all, then

impaired walking

was a wrong diagnosis.

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nursing diagnosis:

acute pain d/t r leg contractured amb pt complains of pain of 9 on 0-10 scale

this is an incorrect diagnosis. contractures take a long time to develop. this is not a pain that showed up yesterday or a few weeks ago. it is chronic pain. the correct diagnosis is chronic pain.

expected outcome:

the pt. will exhibit no manifestations of pain, as evidenced by pt. verbalizes adequate relief of pain within 1 hr.

an outcome of no pain at all is very impractical.

interventions: intervention rationale

1. administer pain meds as prescribed: 1. relieves pain

2. provide leg rub : 2. relaxes muscle

are you referring to muscle spasms? muscle spasms are not one of your assessment items.

3. rom's to r leg : 3. stretches muscles

stretching contracted muscles is painful. you wouldn't do this to relieve pain and because muscle spasms are not one of your aeb items. your interventions only target your aeb items and sometimes what is the cause of the problem (pain) which i would not attempt without advice from a physical therapist.

4. provide activity : 4. provides distraction

specify the kind of activity you mean. you are talking about diversional activity.

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nursing diagnosis:

deficient knowledge d/t diet amb pt is malnourished

the definition of deficient knowledge, specify is absence or deficiency of cognitive information related to a specific topic. dietcannot possibly be the etiology (cause) of a knowledge deficit and malnourishment or any of its signs or symptoms cannot be evidence that proves that the patient lacks any information about their diet. this is a misdiagnosis.
if the patient is malnourished imbalanced nutrition: less than body requirements would be a more appropriate diagnosis.
malnourishment is a medical decision and you cannot use that wording in a nursing diagnostic statement. you must use the signs and symptoms of malnourishment that you observed (documented weight loss, doesn't eat enough food at meals, refuses food, etc.).
need to re-do the outcome and interventions based on the new diagnosis and new assessment information.

milan18400 · Nov 3, 2009

It got all messed up for some reason. I posted a different one but it got deleted (I think because it looked like a duplicate)... Thanks so much for help.

Current Diagnosis:

HIV, Epilepsy, Hypothyroidism, IDA, CVA, hypertension, malnutrition, UTI, hyperlipidemia

Diet:

10/23/09 Peg Tube Intact Jevity @ 80cc/hr Regular-Pureed

Diet Rationale:

Peg Tube for CVA provide nutrients for health maintenance, Regular-Pureed for fully edentulous

Diagnostic Tests:Results: Reason for Abnormality:

EKG:Abnormal:??

WBC (4.5-11):3.03:HIV+

RBC (4.2-5.7):2.86:IDA

HGC (12-17.5):9.8:HIV+

HCT (35-52.5):31.2:IDA

MCV (80-100):109.1:IDA

RDW-SD (36-51):71.2:IDA

RDW-CV (11.6-14.2):18.7:IDA

Albumin:2.9:??

Valproic Acid:21.5:??

Creatinine-Kinase:6:??

Treatments:Reasons For Treatment:

Perform Assessment:??

Provide AM Care:To provide comfort and cleanliness

Maintain Safety Measures:To prevent injury and provide security

Perform ROM to BLE's:To increase muscle strength and flexibility

Change Peg Tube Dressing:To prevent infection at peg tube stoma site

Apply moisturizing lip balm:To decrease dry, cracked lips

Maintain semi fowlers:To prevent aspiration

Provide urinal and bedpan:To provide comfort and cleanliness

Provide psychological support:To assist in coping with being HIV+

Provide activity:To lessen lethargy

Nursing Diagnosis:Expected Outcome:

Impaired walking d/t R leg contractured AMB pt unable to walk

Expected Outcome:

The pt. will exhibit increased physical mobility as evidenced by ambulating, with walker, 30 ft. in hallway by 01/01/09

Intervention::Intervention Rational:

1. ROM's to BLE's:1. Promotes Flexibility

2. Sleep with R Leg extended:2. ??

3. Explain importance of physical therapy:3. Provide education

4. ??4. ??

Nursing Diagnosis:

Nausea D/T adverse reaction to medication AMB emesis of 700 m/l, pt complains of nausea

Expected Outcome:

The pt. will exhibit no manifestations of nausea, as evidenced by absence of emesis and pt. verbalizes adequate relief of nausea within 1 hour.

Intervention: Intervention Rationale

1. provide crackers:1. soothes stomach

2. provide ginger ale:2. soothes stomach

3. administer anti-emetics as prescribed: 3. relieves nausea

4. provide emesis basinwithin patients reach: 4. provides comfort

Nursing Diagnosis:

Acute Pain D/T R Leg contractured AMB pt complains of pain of 9 on 0-10 scale

Expected Outcome:

The pt. will exhibit no manifestations of pain, as evidenced by pt. verbalizes adequate relief of pain within 1 hr.

Interventions: Intervention rationale

1. Administer pain meds as prescribed: 1. Relieves pain

2. Provide leg rub : 2. Relaxes muscle

3. ROM's to R Leg : 3. Stretches muscles

4. Provide activity : 4. Provides distraction

Nursing Diagnosis:

Deficient knowledge D/T diet AMB pt is malnourished

Expected Outcome:

The pt. will exhibit understanding of importance of nutrition for health maintenance, as evidenced by patient verbalizing understanding of importance of nutrition within 3 days.

Interventions: Intervention Rationales

1. Education pt. on importance of nutrition: 1. increase pt. knowledge

2. Education pt's family on importance of nutrition : 2. increase pt's families knowledge

3. Provide pt. easy to read information : 3. ??

4. Refer to dietician ; 4. Provide expert advice

Daytonite, BSN, RN · Nov 3, 2009

I posted an answer based on the deleted post. You provided no assessment data to back up your diagnoses.

milan18400 · Nov 3, 2009

Thank you so much daytonite,

You really helped me. I feel like when I read your help my brain clicked and I'm at least seeing what I **need** to do now. I've revised some things. I'd use the Imbalanced Nutrition Diagnosis but I already have nausea and we can only have 1 from each category. :uhoh21:

Chronic Pain D/T R Leg contractured AMB pt. complains of pain of 9 on 0-10 scale

The pt. will exhibit decreased pain to acceptable level, as evidenced by pt. verbalizing pain decrease to an acceptable level and ability to engage in desired activities

1. Encourage pt. to keep pain diary

Rationale: to identify aggravating and relieving factors of chronic pain

2. Administer pain meds as prescribed

Rationale: To relieve pain

3. Provide pt. with information about chronic pain and options for pain management

Rationale: To educate on the characteristics of chronic pain and pain management to reduce the burden of pain

4. Provide activity such as books, playing cards, TV or a craft

Rationale: To distract pt. from pain

******************************************

Impaired physical mobility D/T R Leg contractured AMB pt. has decreased bed mobility and inability to ambulate

The pt. will exhibit increased physical mobility, as evidenced by pt. able to move purposefully within bed independently by 01/01/10

1. ROM's to BLE's

Rationale: To promote flexibility

2. Explain the importance of Physical Therapy

Rationale: To educate pt.

3. Encourage independent activity

Rationale: To gain strength and self-esteem

4. Provide mobility aids

Rationale: To increase level of independent mobility and increase self esteem

**********************************************

Deficient knowledge D/T deficiency of cognitive information related to diet AMB pt. weight loss of 10 lbs in 6-8 weeks.

The pt. will exhibit understanding of importance of nutrition for health maintenance, as evidenced by patient verbalizing understanding of importance of nutrition within 3 days.

1. Educate pt. on importance of nutrition

Rationale: To increase pt. knowledge

2. Provide quiet environment without interruptions

Rationale: To increase pt. concentration

3. Assist pt. in integrating information into daily living

Rationale: To provide comfort and encouragement when making adjustments to daily living

4. Refer pt. to dietician

Rationale: To continue pt. education on nutrition for health maintenance

CharlieT · Nov 3, 2009

you wrote

"The pt. will exhibit decreased pain to acceptable level, as evidenced by pt. verbalizing pain decrease to an acceptable level and ability to engage in desired activities"

This is not a goal that can really be measured properly the way you have written it. "an acceptable level" is a rather vague statement, and "desired activities" is ummm, well, not a good way to put it. What if the patient desires to swim the English channel, then you missed the goal! Try something like this.

Patient will verbalize leg pain as being a 3 or less on a 1-10 scale by 1500 hours today.

Keep this specific patient in mind when writing your care plan. It should be tailored to one person's needs, right now it is a bit generic. Perhaps something like: "This patient is prone to pressure ulcers due to decreased muscle mass, therefore he/she needs to be turned every two hours and monitored for development of pressure ulcers daily."

Daytonite gave you some great advice which I would follow to the letter.

Think A.D.P.I.E.

Good luck with the care plan, they are a pain but a good learning tool.

Daytonite, BSN, RN · Nov 3, 2009

chronic pain d/t r leg contractured amb pt. complains of pain of 9 on 0-10 scale

the pt. will exhibit decreased pain to acceptable level, as evidenced by pt. verbalizing pain decrease to an acceptable level and ability to engage in desired activities

goals must be measurable. acceptable is not scientific or measurable. since you are measuring the pain on a 0-10 scale then declare an acceptable parameter of pain relief. you must also be clear that the patient must state it.
this goal statement is missing a time frame.

1. encourage pt. to keep pain diary

rationale: to identify aggravating and relieving factors of chronic pain

2. administer pain meds as prescribed

rationale: to relieve pain

3. provide pt. with information about chronic pain and options for pain management

rationale: to educate on the characteristics of chronic pain and pain management to reduce the burden of pain

4. provide activity such as books, playing cards, tv or a craft

rationale: to distract pt. from pain

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impaired physical mobility d/t r leg contractured amb pt. has decreased bed mobility and inability to ambulate

if you do not get specific about the amb items, then your goals and interventions cannot be specific either. what is decreased bed mobility? can he turn in the bed from side to side by himself? if not, state that. if he has slid down in the bed does he need someone to help pull him up? state that. when someone else comes along to read this care plan they should be able to get a clear picture of what kind of problems this person is having. decreased bed mobility tells us no detail.

the pt. will exhibit increased physical mobility, as evidenced by pt. able to move purposefully within bed independently by 01/01/10

again, we don't care about seeing increased physical mobility because that is too broad a statement. what does move purposefully within bed independently mean? be more specific. state exactly what independent purposeful movement you expect him to be doing as a result of your interventions. would that be using the side rails to help himself turn or reposition himself in the bed? state that. you need to be specific.

1. rom's to ble's

rationale: to promote flexibility

2. explain the importance of physical therapy

rationale: to educate pt.

3. encourage independent activity

rationale: to gain strength and self-esteem

you need to state what the independent activities are. so far, we know absolutely nothing about what this patient can or cannot do in this bed. everything you mention is vague.

4. provide mobility aids

rationale: to increase level of independent mobility and increase self esteem

what specific mobility aids does the patient need? name them. i would replace interventions #1 and #2 with interventions on teaching the patient how to use any assistive devices that they need. also, an appropriate goal would be that the patient has learned and can demonstrate the proper use of an assistive device.

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deficient knowledge d/t deficiency of cognitive information related to diet amb pt. weight loss of 10 lbs in 6-8 weeks.

the correct diagnosis is deficient knowledge, specify. you specify the subject of the knowledge deficit in the diagnostic title. so, if i understand this correctly, the patient lacks information about proper diet (what to eat). the correct wording for that is deficient knowledge, diet d/t lack of information amb 10-pound weight loss in 6-8 weeks.
your interventions should target the evidence that you have that resulted in you picking the diagnosis in the first place: weight loss of 10 lbs in 6-8 weeks. re-think your interventions. do they look like they are addressing someone who has been losing weight? do you know why he has lost the weight? is lack of knowledge really the reason or is something else going on. you said he was nauseated. there are strategies that you can teach him to keep his nutrition and calorie consumption up while working with the nausea. i get chemo and get nauseated. there are things that can be done to keep calorie consumption up when nauseated or not feeling well. see http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff_index.html and http://www.stvincent.org/ourservices/hospice/preparing/default.htm

the pt. will exhibit understanding of importance of nutrition for health maintenance, as evidenced by patient verbalizing understanding of importance of nutrition within 3 days.

again, your goal is too vague and too broad, but so are your interventions. if one of your teaching interventions was about what food groups should be eaten daily one of your goals would be for the patient to state what foods would be appropriate for a full day of meals.
how will we know when the patient verbaliz(es) understanding of importance of nutrition? that is vague and unclear.

1. educate pt. on importance of nutrition

rationale: to increase pt. knowledge

2. provide quiet environment without interruptions

rationale: to increase pt. concentration

???

3. assist pt. in integrating information into daily living

rationale: to provide comfort and encouragement when making adjustments to daily living

i have no idea what you are talking about or what it means.

4. refer pt. to dietician

rationale: to continue pt. education on nutrition for health maintenance

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goals are the predicted results of our nursing interventions (actions). we perform nursing interventions on the signs and symptoms (the amb items) that the patient has for each of the nursing problems (nursing diagnosis). goal statements have four components:

a behavior
- this is the desired patient response/action you expect to see/hear as a direct result of your nursing interventions.
- you must be able to observe the behavior

[*]it is measurable

criteria that identifies exactly what you are measuring in terms of
- how much
- how long
- how far
- on what scale you are using

[*]sets the conditions under which the behavior should occur

such conditions as
- when
- how frequently
[*]take into account the patient's overall state of health (this requires knowing the pathophysiology of their disease process)
[*]take into account the patient's ability to meet the goals you are recommending
[*]it is a good idea to get the patient's agreement to meet the intended goal so both the nurse and the patient are working toward the same goal

[*]have a realistic time frame for completing the goal

long-term goals usually take weeks or months
short-term goals can take as little time as a day
it all depends on knowing what your nursing interventions are designed to do and what you believe your patient is capable of doing.

milan18400 · Nov 7, 2009

Again, thank you so much for your help. I've been spending so much time on the care plan and I really am thinking it's coming together nicely!

I have totally fixed my chronic pain and impaired physical mobility diagnosis and i think they're very good now! I have nausea left and I am thinking of changing my deficient knowledge diagnosis to "ineffective protection".

Nausea D/T adverse reaction to medication AMB emesis of 700 ml, pt. complains of nausea

The pt. will exhibit no manifestations of nausea, as evidenced by absence of emesis and pt. verbalizes no nausea.

*******

1. Provide crackers

Rationale: soothes stomach

2. Provide ginger ale

Rationale: reduces nausea

3. administer anti-emetics as prescribed

Rationale: relieves nausea

4. Provide emesis basin

Rationale: provides comfort and cleanliness

*************

Deficient Knowledge, disease process D/T deficiency of cognitive information related to HIV AMB pt. not taking proper precautions and not understanding the disease

1. explain the importance of annual flu shot

Rationale: to protect against yearly influenza virus

2. teach proper hand washing technique

Rationale: to prevent the spread of germs

3. educate pt on the disease

Rationale: to increase pt. knowledge

4. provide pt. with information on joining an hiv support group

Rationale: to provide pt. with continued access to knowledge

Daytonite, BSN, RN · Nov 14, 2009

Again, thank you so much for your help. I've been spending so much time on the care plan and I really am thinking it's coming together nicely!
I have totally fixed my chronic pain and impaired physical mobility diagnosis and i think they're very good now! I have nausea left and I am thinking of changing my deficient knowledge diagnosis to "ineffective protection".
Nausea D/T adverse reaction to medication AMB emesis of 700 ml, pt. complains of nausea
The pt. will exhibit no manifestations of nausea, as evidenced by absence of emesis and pt. verbalizes no nausea.
*******
1. Provide crackers
Rationale: soothes stomach
2. Provide ginger ale
Rationale: reduces nausea
3. administer anti-emetics as prescribed
Rationale: relieves nausea
4. Provide emesis basin
Rationale: provides comfort and cleanliness
*************
Deficient Knowledge, disease process D/T deficiency of cognitive information related to HIV AMB pt. not taking proper precautions and not understanding the disease
1. explain the importance of annual flu shot
Rationale: to protect against yearly influenza virus
2. teach proper hand washing technique
Rationale: to prevent the spread of germs
3. educate pt on the disease
Rationale: to increase pt. knowledge
4. provide pt. with information on joining an hiv support group
Rationale: to provide pt. with continued access to knowledge

Looks good, rational.

SRK77 · Nov 15, 2009

My first care plan did not look anywhere detailed as this. Mine always look simple. However, my instuctors don't write all over them, so it's working for me.