First Care Plan/First Day on Clinical Help....Please

[WndrWmn]

LOL. Ok well today was my first day in a LTC facility. My resident is a doll fortunately but I must say I am not prepared for the nursing notes, paperwork, care plans.... I have every book imaginable on NANDA's but I am having a hard time with all of this. My instructor wants it completed in the am.....thats if I do not get stuck in a foot of snow lol.

OK so any help advice tips etc would be greatly appreciated.

M.S. is alert and oriented.

DX: Hypertension, Peripheral Nerve Damage, Unsteady Gait secondary to Peripheral Nerve Damage. She had cancer in her right breast so she has nerve damage in her right arm she also is S/P a carpal tunnel release September 2008. Walks with a rolling walker. Ambulates well. I dont know where to begin. I have spent the past 4 hours looking up all of her meds. Im overwhelmed. The peripheral nerve damage would I put that in the sensory and motor as well as the musculoskelatal section? I feel stupid.

[midlife_nurse]

Nursing school is SUPPOSED to make you feel stupid... you will survive.

My first care plans were crap, as were everyone else's, and my instructor was very cool. It's a learning experience! Put something in each column/blank/box and try not to stress.

Your patient has condition (a), you will do (1, 2, 3) to address that condition, and the outcome you will look for by end of shift is (whatever) was the format we used... three columns for each patient.

The first discussion of care plans was a good learning experience, and not everyone had everything filled in just right, and it was OK. Don't stay up all night obsessing!

Good luck to you, Future Nurse.

[WndrWmn]

LOL I know and let me tell you I do feel stupid lol. I filled in all the boxes (Im starting to enjoy this..... I feel like a detective lol)....except the main priority LOL! Altered Tissue Perfusion.....can I use this for Hypertension bc I am having a lot of trouble finding a NANDA for Hypertension.

[Angel@MyTable, RN]

I just finished my first semester of an RN program, and I finally got the hang of care plans....and yeah, I feel for you on how many hours you need to put into a care plan. My first couple....6 plus hours (meds, Dx, Tx, holistic intervention, and something we were going to teach our pt). They do get easier....thank god!

My suggestion is (what we were told) is to focus on the ABC's....airway, breathing, circulation, for the pt's priority Dx.

[Daytonite, BSN, RN]

i didn't see this post until today. was it hidden somewhere else on the allnurses forums?

is this the same patient with hypertension that you pm'd me about? decreased cardiac output r/t increased contractility.

so, she has nerve damage secondary to chemotherapy or surgery? as a result she has difficulty moving her legs and arms. that is a mobility problem: impaired physical mobility r/t neurological impairment aeb unsteady gait [and what ever the specific movement deficits are with the right arm]. if there are issues of sensation and feeling in the limbs then you have disturbed sensory perception, tactile r/t altered sensory reception. the fact that she walks with a walker is a treatment and intervention. it can also be a risk factor for risk for falls along with her unsteady gait.

[StudentNurseMindie]

Gawd! I remember my first few care plans. They were BAD.

We aren't allowed to use NANDA for some reason. Must be an Ohio thing maybe.

[tothepointeLVN, LVN]

I've never had problem with care plans but I have to second the notion that no one expects your first one to be perfect. Hers how student me does it

Lists all the problems for my patient on a piece of paper. Find a theme group them together then find the most urgent group of problems formulate a NANDA diagnosis for it and do the are plan for that repeat if you need more than one diagnosis.

Remember if its too perfect they'll think you've been cheating lol ;D