Desperately Need Help With Care Plans

I hope everyone gets a kick out of this. I just finished a refresher course and had this great instructor who worked in ER for a long time. She told us certain things should always be in our daily plan of care for a patient and if they were you could not go wrong.

Someone else made an acronym of the points that goes like this:

S 'n' M Excites Frank!

Ha ha ha ha

Safety, Nutrition, Maslow's, Mobility, Elimination and Fluids

It's more like S 'n' M(squared) Excites Frank! Frank must be a pretty kinky guy! Can you tell that the nurse who made up the acronym had been a psych nurse for many years!

Anyway, from a practical point of view with nursing, it works. It gets the patient through the shift.

Safety is always priority, because if your patient isn't safe, then you will be writing an incident report and too many of those means you won't have a job and your patients are probably walking around with a lot of bumps and bruises.

Mobility is huge.

Even if a patient is bedridden (say a stroke patient), then you better be rolling them around to make sure they have good lung expansion on both sides. (ABC's!!) Think circulation when thinking mobility also, in regard to risk for blood clots (possibly another stroke, heart attack, DVT and PE- pulmonary embolism). Circulation again - in regard to potential bed sores. You may not see the damage to tissue, because it's happening below the surface. Next thing you know, whammo - decubs! Turn, use pillow logically and use the bed booties.

If the patient can be mobile, even up in a chair, then get them there as long as you have a doctor's order to do so. If you aren't sure because the patient just came in or they are getting weaker fast, then get that MD to order a physical therapy evaluation. Until then, have that patient turning. There are always those difficult calls, say an Alzheimer's patient who has a history of falls and is weak, but you don't want them to get weaker by keeping them in bed. The last clinical I had recently, the RN wanted the patient in a chair, so did I, the care assistant wanted a posey on that patient if they were going to be in a chair. I cringe at using restraints, but sometimes they are warranted. The doc knew the patient from the nursing home and ordered a posey while in the chair and an order for PT. Other option, get on the phone and have a family member stay with patient so they don't have to be posied. Now, you just have to see if they try to climb out of bed also and get an order for posey in bed if you have to. Ahhh! I hate restraints! It's a difficult balance, but I have to always remember that my shift is not the only shift of this patient's life. It's a collaborative effort, so do what is good for the patient now with future goals in mind. (In this case, PT).

Nutrition is very related to strength and diagnosis.

In the case above, you'd see how you need good calorie intake to keep a skinny little old man from becoming more weak. Then, what do you always need for old people? - If their diagnosis doesn't contraindicate it, fiber doesn't hurt to keep the bowels rumbling around. Mushed up food is not as palatable as regular food, so give it to them if they don't have any swallowing issues. (ABC's - A&B apply to people who can't eat well because of a stroke, no teeth, etc. Speech evaluation if you notice coughing. Don't want to give anyone an aspiration pneumonia!) Water is a part of nutrition that overlaps with fluids. Cleans your palate, and your mouth, prevents nasty infections in your mouth (along with teeth and gum cleaning in the morning), prevents dehydration and keeps the bowels rumbling once again! Do they need supplements. Is their neutrophil count low, (so they can't have fresh fruits, salads, and no flowers in the room because they are on reverse isolation). Do they need free H20 or juice (depending on their sodium level, are they vomiting or having diarrhea). Can they hold the fluids and food down. Do their bowels need a rest with a liquid diet (i.e, acute colitis). Do they have the gag reflex? Do we need to get their bowels woken up from anaesthesia by starting them on a clear liquid diet. If they need potassium, can you give it to them orally. If their potassium won't come up, do they need Magnesium? If they have asthma, do they respond to magnesium supplementation. How's the Calcium level? K+, magnesium and Calcium are all absorbed well in the gut. Their levels are all related and contribute to good muscle contraction and heart rhythms. Do they need low vitamin K, because they are on Coumadin. In this case, get a dietary consultation for patient teaching, give them a hand out and teach, quiz, etc.

Use your common sense and learn as much about nutrition as it applies to the particular diagnosis. You will learn a lot here and it very much relates to fluids (riders and electrolyte balance).

Maslow's always needs to be included. You need to see what level your patient is at and then get to that level with them so you understand how you will communicate with them, give them what they need and do your teaching appropriately.

Elimination is very related to mobility and nutrition and fluids.

How are they going to get to the bathroom? and getting there safely?, or do they need that commode or a bedpan. Think logistics and need for mobility tempered with safety and reality. They are not going to be in the hospital forever!

Are they eating enough to even make a bowel movement? (I hope so, if not, then that is the goal). Do they have enough fiber, oral fluids and mobility to keep them regular? Do they have a history of bowel obstructions? Look at their baseline, complications, patterns of output and goals.

Are they post-surgical. If so, do they have bowel sounds, gas, cramping? Have they urinated?, Is the suprapubic area hard, distended? Do they need to be straight-cathed to see if their kidneys are making urine output? Do they need fluids, are they 3rd spacing?

** I have learned how important 24 summaries of I's & 0's are! Review them. Learn their importance. This is a primary nursing responsibility. You are the first person to notice changes and should try to recognize situations where I&O problems are apt to happen so if they do, the problem gets moved on right away. It never hurts to have a doc review this if in doubt. You'll end up learning more when you ask the questions also. ***

Do you see how this all has moved very to Fluids?

- OK, be aware, I went off on this subject. Stick to the basics. Fluids are complex. It's good to poke your head in books, talk to the nephrologist, talk to the cardiologist, read about endocrinology. This is the cellular level of nursing and medicine, but there are also some basics to always remember and that's what goes into your care plans. Always know why they are getting fluid and why THAT PARTICULAR TYPE OF FLUID. Ask the doc if you can't figure it out. No use beating your head against the wall, right? We are here to learn and no one is a brainiac 24/7.

The part about care partners will not affect you until you start working. The stuff about SIADH, try to learn it at some point. The inter-relation between the endocrine system and fluids is very interesting and really comes into play in cancer and post-op patients. Learn about antidiuretic hormone at some point and understand its importance in fluid balance.)

Fluids include ORAL, G-tube, NG-tube, intravenous, intra-arterial, intraosseus, intrathecal.

Per my Med-Surg book, 2002 Ignatavicius and Workman, Med/Surg Nursing, Critical Thinking for Collaborative Care. . "These solutions and medications may be administered for therapeutic or diagnostic purposed, including the following:

• Replacement of fluid, electrolye, and nutrient losses
• Administration of anti-infectives
• Blood and blood product transfusions
• Administration of enhancing agents for diagnostic imaging

My notes from class say are more general:

1. Maintenance/ of daily fluid requirements

Learn the difference between crystalloids and colloids. Understand what isotonic, hypertonic and hypotonic is in terms of osmolality compared to the osmolality of plasma.

Memorize what kinds of fluids are isotonic, hypertonic and hypotonic.

Begin to understand what fluids are used in what situations (chronic and acute situations) and learn why.

Learn the different blood parts/products, when they are used and why they are used.

2. Replacement/ of loss of fluids - drains, insenisble loss, diarrhea, wounds, bleeding.

3. Treatment - used as a medium to deliver therapy, e.g. (K+, antibiotic, hyperalimentation.)

4. Diagnosis - used as a medium to deliver diagnostic dyes

5. Palliation - used as a medium to deliver pain medication, nutrition.

Do the 24 hour review of fluids. It is every nursing shift's responsibility. . Do not getting the habit of slacking in this area. Too many things are missed due to this and they can be things that are critical. If things look imbalanced, investigate why and ask yourself if the problem is being addressed. If it is not, then do what you can to correct a problem and/or notify a doc for further evaluation.

Just remember to think of what a typical patient that has same diagnosis would look like. If you don't know that, now is your time to find out, so look in your med/surg book. Then make sure your care plan addresses whether or not the patient is "balanced" fluid-wise or not. If yes, then you can always write done "potential for fluid and electrolyte imbalance" if that is a common problem for this type of patient. Then you just write - monitor labs results for electrolyte abnormalities and monitor I & 0's for imbalances (over or under hydrated), or you can write "take off orders for blood draws to monitor fluid and electrolyte status and make sure they get drawn and lab gives me a result. Report abnormalities, institute oral or IV therapy as appropriate or as ordered." Then or course, give every way you can do it orally before resorting to IV if oral is not contraindicated.

Here are some typical I & O situations:

Think about who is at risk for dehydration and why? Think about who is at risk for a fluid overload and why? Is the Na+ level high or low. If they are dehydrated, is it because they are putting out too much fluid or have diarrhea, or because they are not taking in enough fluid.

Their mental status and energy level is very affected by fluids. When was the last time you were hot and didn't drink water regularly for a few days. Did you feel like doing jumping jacks, doubtful.

If they are post-surgical, watch for adequate urine output and mental status changes. **Learn the dangers of D5W post-surgery and in general, how it can contribute to cellular swelling and increase intracranial pressure. Read some cases studies on this.**

Is there some kind of problem that affects them in which they cannot eat or drink (mental or phyical problem)? If so, when are the fluids going up. Watch the K+, Ca+ and Mag+ levels. Always remember that K+ is a drug - too much can make your heart stop. If a K+ rider is needed, best given through a large vein with a small gauge IV catheter to prevent pain at the IV site. If lidocaine is added, realize it can mask pain, so watch that IV site. Lidocaine is a drug too. Become aware of it's affects. If K+ needs to be given, can you do it orally or through a G-tube rather than through an IV. If the K+ level will no come up, get a Magnesium level. (K+ will not come up if Mag is too low). When will this happen? In patients with lots of watery diarrhea. Get a fecal incontinence bag on those patients. You need to know how much fluid they are losing in order to replace what they are losing AND give them their daily requirements.

Look at the output. Is it "sick" looking?

Diarrhea, bloody stool, steattorhea, solid as a rock, C. diff green and smelly, yuk.

Urine - is there enough? Is it smelly, is it concentrated? Does it have while blood cells in it? Is my patient eating any fruit (water content?), drinking, do they have good peri-care if that foley is in. If they have a suprapubic, is the site red, tender, distended? Is my patient so big, peri-care is difficult? If so, get however many it takes. Do they have to have that foley? Does my patient have a fever? Are they losing fluid in sweat, insensible losses. Do they need replacement fluid on top of that?

Lungs - does my patient have CHF? are they coughing? Do they have crackles or rhonchi? Make them cough. Does upper airway congestion clear? Does the crackling clear? Do they need some Lasix. Are they edemetous? Are they on fluids and getting overloaded?

These are the extras:

----- If a care tech isn't getting it done, tell them it is imparitive for care. Is this a problem for all the nurses? If so, maybe all the nurses need to bring this up at a meeting. If it's just one care tech for everyone, let the super know. If it's just that care tech with you, let them know that your nursing care needs to look good, if they are not being responsible and in doing so, make you look bad to the docs and your supervisor, let them know you're going to have to say something to someone because you can't put your job on the line. (You can't let negligence to duty go and letting it go makes you negligent and on the hook for it). If there is a legitimate excuse or you can estimate output, put something down rather than nothing, but put the reason why it is not exact. (Used the toilet before hat was given. Pt. took hat out of toilet.). Try to write down the number of voids at least. But don't completely guess at cc's and never make up anything! Let the next shift know exact I&O's weren't obtained and that you have told your partner you need exacts now. Write an order for strict I & O's if you can. Get a doctor to order it. Get those I's and O's going. always, if you empty something, record what you emptied and communicate it to the partner somehow, flowsheet is the best way. So many patients need I's and O's and considering how sick most patient's are, it's unusual, in my book to see someone who doesn't need them. (At least on a med/surg floor). The patient didn't just come in with nothing going on. If they were well enough, they'd be at home or somewhere else. If they can't be somewhere else, then things are out of whack.

--------------

**Learn about SIADH** Syndrome of Innappropriate ADH, watch for low Na+ levels. It is complicated, so take some time to undestand it and read some case studies. I had a patient with this and then his mental status went bad. He was taking Ambien at night, so I thought he was just tired in the morning, thought I'd let him wait to do that wash up. Nope, bad idea. He was actually becoming somnolent. When someone is falling asleep right in front of you mid-sentence, it's a problem. EKG showed heart block, we sent him to telemetry. By the way, his foley looked like a Mai Tai with Oxi-clean in it!) This guy had been on a fluid restriction the night before and had a 250cc bag of 3% saline up over the day prior. Not .3%, 3.0%. In the morning, I did notice that no one had taken the water pitcher out of his room. (That should have been a clue to me right away that the care was not on track. When I asked him about his fluid restriction, he told me no one had told me about it. Here's another clue.). This guy was a confabulater. He would tell me anything to make things seem OK and was not concerned about anything despite the fact that he had been in the hospital for days, hadn't eaten well for awhile and had cancer. Hmmm... something was wrong here. Yes... it was his mental status. Sometimes it's hard to get a grip on. When in doubt, ask your peers, a more senior nurse who has time to help, if not available, a supervisor, if not available, a doc. What did the nurse who gave you report say? Read the chart, when in doubt, call the doc. Sometimes you don't have time to figure things out on your own. Call the doc. Make sure you have an assessment to report before calling and let them know that you aren't sure if this is their baseline if that mental status has changed. Better safe than sorry. You do work for the patient, remember that. This guys was starting to have mental status changes due to cellular swelling in his brain. Yikes, that's a situation that deserves a monitors if not the ICU.

Remember, I'm a nurse with just 3 years of experience, or just 3 years of experience, however you want to look at it.

Geez - I better get off my butt and start working on my resume and looking for a job, eh?

Good luck. Hope I was helpful. (and not confusing. Things come with time. Just learn it as it applies for your care plans. Learn it like a lecture/class when you are in class and studying for tests.

??‍⚕️

sylviamon said:

thank you for your response. i really appreciate it. what are the ABCs?

ABC'S: A=Airway, B=Breathing, C=Circulation. Assessing if they have a patent airway, are breathing, and do they have a pulse.

Good luck with the care plans. If depend a lot on my text books, internet, amd care plan books. I have to do weekly care plans for Med-Surg and then for clinical. Sometimes i hit the nail on the head and other times hit my finger.

Jenn

LVN2006 said:

any help?

I had a great teacher who told me to remember three things that should direct your care plan interventions. These are ASSESS, ASSIST, TEACH.

truliblessed said:

HELP!!!!!!!! Trying to write first careplan

The patient has 2nd and 3rd degree burns and a left ankle fracture ,and a history of hypertension and diabetes. How do I prioritize. I was thinking maybe impaired mobility, and risk for infection.

Any suggestions, because I am completely lost and frustrated.

Prioritize according to ABC's and Maslow's Hierarchy.

Depends on how stable the patient is and when the 2nd and 3rd degree burns occurred. If he is a "fresh" burn patient, then airway and electrolyte imbalances take priority. Of course, pain issues also are priority throughout the course of care.

Hepatic Encephalopathy is also known as coma resulting from liver damage. A high mortality rate is associated with this disorder, and the cause is unknown. (Source: Med Surge textbook).

Two major groups of signs and symptoms you'll be assessing for are neurological and respiratory (remember, the brain controls the respiration rate).

I'm going to assume your patient has lung sounds, let's say crackles, and a productive cough. This is your "as evidenced by".

So your nursing diagnosis is "Ineffective Airway Clearance related to depressed central nervous system function and dyspnea as evidenced by crackles and productive cough."

For goals, pick a measurable repiratory sign, like "O2 sat will remain above 90% during hospital stay" or "respiration rate will remain at 15 per minute throughout stay."

This gives your first two interventions: 1) monitor O2 sat Q2H; and 2) monitor respiration rate Q2H.

Now come up with as many more interventions as your teacher needs, mainly neuro or respiratory. Here's some for starters: elevate head of bead; auscultate for lung sounds; monitor for signs of dyspnea such as nasal flaring, use of acessory muscles, anxiey, & retractions; humidify and push fluids in order to thin secretions; assess pupil size and reaction; assess level of consciousness using Glascow coma scale; assess grip strength; assess reflexes. Of course you also want to assess for pain, administer meds, and check lab values too. You can teach deep breathing & coughing, and also explain why you are doing the assessments you are. Explain something about the pt's medications.

That should get you started. Other good diagnoses might be Activity Intolerance (cardiovascular deconditioning), Impaired Skin or Tissue Integrity (pressure sores from decreased mobility and bed rest), or Constipation (lack of motility due to inactivity or medications).

Good luck!

Well, you've got your nursing diagnosis; Impaired Skin Integrity, so next you need your "Related to," which will be specific to your pt, but some common ones are physical immobilization, mechanical factors (pressure, restraint,injury, surgery,etc), altered nutritional state (obesity or emaciation), alterations in turgor (edema), or skeletal prominence.

For your "as evidenced by," you'll use your assessment findings, i.e, does your pt have a wound, pain, itching, numbness, etc.

Next, your "desired outcomes," which would be how the pts diagnosis should show improvement, i.e., wound displaying signs of healing, pt participating in treatment plan, etc.

"Actions/interventions" are going to be your ongoing assessments; ex are identifying underlying condition/pathology, noting changes in wound, determining depth of injury, evidence of infection, evaluating risks for further injury, using appropriate dressings, repositioning schedule, encouraging mobilization, teaching.

So if your problem is a pressure ulcer, your care plan may look something like this;

Impaired skin integrity related to physical immobilization, pressure, and skeletal prominence as evidenced by open purulent wound to coccyx.

Desired outcome:

Pt will be free of purulent drainage within 48 hours. Will display signs of wound healing with wound edges clean/pink within 60 hours. Will participate in prevention measures and treatment program.

Actions/Interventions:

Assess wound with each dressing change (rationale:provides information about effectiveness of therapy and identifies needs)

Obtain culture of wound on admission (rationale; to identify pathogens and therapy of choice)

Administer ordered antibiotic (rationale:treatment of infection)

(And on and on, there are all kinds of actions/interventions for skin integrity, and this is usually the longest part of the care plan.)

I'm sure others can add to this, I haven't done a care plan since I was in school 5 years ago, but these are the basics that I remember.

Here is a sample of the last care plan I turned in. The first page is the "example" and the following pages show the 3 nursing diagnosis I chose, and the interventions/rationales that I included. Hope this helps.

The patient that I took care of this day had extensive facial lacerations, but was otherwise healthy...no other problems, and was ready to go home.

careplanSAMPLEj.doc

1. Collect your patient data, including subjective (what pt states) and objective (what you see). In texts - they may be called "defining characteristics."
   
2. Cluster those data & see the related factors causing #1 (i.e. medical diagnosis, pathophysiology, current health status).
   
3. Look at reference for nursing diagnosis which has your defining characteristics & related factors.
   
4. State your goal / patient outcome with measurable evidence (what do you want patient to demonstrate or verbalize and when is a realistic time frame to accomplish this patient outcome). This is focused on patient's behavior, not the nurse's behavior.
   
5. Interventions. What will you (the nurse) perform that will address the patient data and lead to the patient outcome.
   
6. Evaluation. Look at your goal / patient outcome / measurable evidence. Did you meet the criteria? If yes, then outcome met. If no, look at interventions that need revision.

• Hope this helps.