This whole nursing care plan deal

  1. my instructor is very vague. She seems to not like any care plan I write up, and gives the same remarks everytime she hands them back "it's not measureable, it's not patient focused, the interventions are not nursing interventions..." SO I would like to show you this new one I did here and get some feedback, pretty please!

    Basic Need: Safety

    Problem Statement: High Risk for injury as evidenced by recent, frequent falls (this is a 93 year old with mild dementia, but really is quite sharp and independent)

    GOAL: Pt will demonstrate use of Lap Buddy and will be wearing it while in her wheelchair when I come onto Shift, and q2h when I check on her. She will demonstrate use of Call signal when in her room or in the bathroom when I come onto shift and q2h. She will also sleep with her alarm sensor in place.

    PLAN: Assess vital signs
    Perform Reality Orientation
    Keep Enviro free of clutter
    Assess level of conscious
    Keep Call signal nearby within easy reach
    Make sure Pt. Knows where signal is, the proper way to wear lap buddy, and that lap buddy is of a proper fit
    Observe for any changes in orientation.
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  3. by   MIA-RN1
    I am not a nurse yet but we were taught that if you are using a 'risk' diagnosis, the outcome/goal would be a statement of "pt remains free of falls'
    Your outcome/goal must be measurable and the easiest way is have it occur during your shift. Also, your interventions could be broken down a bit. Each goal should be individual, you have a couple in your statement. All you really need to do with it to polish it up is to break it down a bit.
    I might go like
    Dx: Risk for falls AEB recent, frequent falls.
    Outcome (goal): 1 Pt will remain free from falls for the duration of this shift
    Outcome 2: Pt will demonstrate proper use of Lap Buddy by the end of this shift.
    Plan/ Interventions:
    1. Assess vital signs
    Assess pts level of consciousness and orient as needed.
    Keep Enviro free of clutter
    Educate pt on necessity of assist with transfer in order to avoid calls.
    Educate pt on use of call bell
    Keep call bell within reach at all times.
    Interventions 2:
    Assess pt for ability to use Lap Buddy correctly/safely
    Teach pt proper use of Lap Buddy
    Educate pt on necessity of using Lap Buddy in order to prevent falls
    Allow patient supervised practice on use of Lap Buddy

    Something like that. Its patient focused (PT WILL) and measurable (BY END OF SHIFT)
    You are almost there!
    PS I don't know what a Lap Buddy exactly is so those interventions may be kind of off.
  4. by   azrn22
    Try giving your goal a real measurealbe goal. A 93yr old with dementia is probably NOT going to be able to verbalize how to use the lap buddy or call light 50% of the time, let alone the rationale behind using them.
    Change your goal to something will become compliant with activity restrictions within one week.
    That is a general goal but measureable and realistic.
    Care plans are rough, but once you get the idea of what your insructor wants they are pretty easy.
    Don't over examine some things, sometimes we can be so close to the tree we can't see the forest!
    Good luck.
  5. by   sjrn85
    Dx. should be "Potential for injury AEB frequent falls."

    To say "Risk for falls AEB frequent falls" is kind of redundant.

    Interventions would include assessing vs, teaching pt. re: safe transfers, getting up slowly, assess need for therapy consult for ambulatory dysfunction, assess meds. which may contribute to pt. falls, maintaining safe environment, yada, yada, yada.

    Goal would be that the pt would be free from injury during hospitalization, pt/caregiver would verbalize understanding of ways to minimize risk for injury at home, etc., etc., etc.

    IMO, they're OK as a tool for learning how to think like a nurse, but major time wasters when you're trying to manage a full pt. load.

    Do you have any care plan books that use NANDA? That might help. A lot of it is just semantics, IMO.
  6. by   RazorbackRN
    You are leaving out the etiology (related to) component of the nursing dx. If it is a "Risk for" dx, there shouldn't be an AEB component.

    For example, I would use: Risk for Injury, related to unsteady gait (or frequent falls).
  7. by   MIA-RN1
    omg I just reread and see I totally left off the r/t lol.
    Blame it on too little sleep and too much stress over psych nursing
    Thanks to all who noticed!
  8. by   tcdtx
    I just graduated last night from an (ADN) RN program. If it makes you feel any better, it didn't matter what I wrote on my care plans, the teacher always has a "better" way of doing it. It took me til my second part of my last semester to get care plans back that didn't have red marks all over them! We were taught:

    Nursing DX: Risk for falls R/T....(reason for falls?)....AEB recent history of falls.
    Goal: (shorten your goal to one main goal) ex: Patient will demonstrate proper use of call lights for assistance with ambulation today.
    Interventions: (add a time to interventions that need to be repeated) ex: assess LOC Q4H, educate client to use of call light, keep call light in reach, assess for proper Lap Buddy placement Q2h and PRN, etc........

    I used a care plan book, and it was helpful. It had all the NANDA-approved nursing diagnoses (along with goals, outcomes, interventions, etc.)
    Most importantly, don't stress over it. It gets easier with practice, and knowing what your instructor is looking for.

    Good Luck!