Nursing Care Plan

Nurses General Nursing

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So, i'm at the end of my second semester of nursing school. We have a multiple problem plan of care due soon. We have to work 3 different nursing diagnoses out completely.

I have my first one done. I made this one : Impaired mobility r/t pain from surgery and old age AEB: facial grimacing when moving(o), pt says, "I'm really sore" (s), Pt is 82 (o), difficulty moving (o), shaky gait (o)

My outcomes/goals for this are:

Have pt walk around nurses station 3x a day by discharge

verbalize feelings of increased strength and ability to move when felt by 24 hours

demonstrate use of walker by discharge

My second diagnosis is the one i'm having trouble with

self care deficit r/t pain from surgery AEB inability to put clothing on lower extremeties (o), inability to put on shoes (o), inability to access bathroom (o)

Really what i'm asking is..

Am I going in the right direction? :uhoh3:

Yeah, i've already done 2 nursing diagnoses with 10 interventions, rationales, and patient responses. got one more left to do and it's the one that's bothering me the most. I have to do a narrative charting also that explains just about every single hospitalization, surgery, and everything else. Then I have to do medication information and reasons why labs are low or high on another patient. ahh! :smiley_ab

Specializes in ACLS.

When I hear (elderly, pain, surgery) I think of:

Alteration in Bowel Elimination: Constipation

Powerlessness

Impaired Skin Integrity

Impaired Physical Mobility

Knowledge Deficit

Self Care Deficit: *

I'm sure there are more.

yeah, she doesn't have constipation, no powerlessness, no impaired skin integrity, i've already used impaired mobility, might can use knowledge deficit, and already used self care deficit.

=/ I despise care plans :banghead:

Specializes in ACLS.

yes, they are a pain in the rear. When I was in the LVN program I always wondered why there was not a class on nursing care plans and labs. I guess because you get a little bit with each system.

I'll tell you what is cool, get the care plan flash cards or borrow someones. Wow, we had a girl who took hers to every clinical and she actually did very well. Care plans are real snoozers but they are the foundation of your care.

yea that's true. i'm so glad i found this site. I think that from the help i've got from this site, i've got so far 2 of the best care plans i've ever done in my 2 semesters.

This is my intervention for anxiety.

, sans-serif]Teach patient (pamphlet and verbally) the procedure she will going into, the anesthesia, the risks, and what to expect when coming out of the ERCP, and also making sure that they are on a level she can understand. Teach that the patient will be lying on her stomach and have a lighted scope inserted gently through the mouth, and down the throat to the duodenum into the ampulla which serves as the "drain for the liver and pancreas. A small catheter is placed through this opening and dye is carefully injected so that x-rays can be taken , sans-serif], teach that she will not be able to have anything to eat or drink 8 hours before having the test, teach that the procedure takes 30-60 minutes, the risks are minimum with most being upper respiratory problems from the scope being inserted, the drugs being used are more than likely propofol, midazolam and fentanyl and might cause a low blood pressure.

Specializes in psych, addictions, hospice, education.

Be sure to use words that the general public will understand in your teaching. Medical terms aren't necessarily the ones you want to use. For instance, lots of people don't have any idea what a duodenum, ampulla, or scope are. Aim for a fifth grader's comprehension level unless you're sure a patient will understand you (the patient is a nurse, for example). It's generally thought that most of the American population comprehends at that level, especially when under stress. The ability to understand can be influenced by illness, anxiety, career, and education level. Draw pictures. Until you're confident your patient will understand teaching, it never hurts to run it by someone not in the medical field, to see if that person can understand it all, or run it by another student. I know there's not usually time to do it...just at least consider it...

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