Concepts in care plans and a rant

[LilPeanut]

Ok. Today was a very frustrating day for me - We had our first day on care plans. We had a 3 hour lecture then we were supposed to go back and write care plans in lab about 3 cases.

I'm just not thinking the right way yet and I wasn't able to communicate effectively to my teachers about my issues. I would try and give an example and they would get so hung up on the details of the example without answering the conceptual question behind it.

Ok. So, one of them was something like this:

Jane Smith has double above the knee amputations, is diabetic, obese and confined to a wheelchair. She is very active and often agitated. During her periods of agitation, she waves her arms around wildly and tends to sweat heavily. She has developed a 7cm x 3cm injury to her skin underneath one of her abdominal folds.

Now. I understand that the skin integrity is the most important thing. I really do. But out of all that, I see the (rather extreme) agitation as being very abnormal and potentially a huge contributing factor. Yes, treat the skin issue. But shouldn't the second priority be making sure she gets a psych eval or something?

I was just so frustrated when I was trying to talk with my instructors because none of them were understanding my train of thought and therefore couldn't help me redirect it to how it's supposed to be going. For me, it just doesn't work to say "this is the way we do it, now think like this." I have to understand what it is we're doing, why we're doing it etc.

This is my first quarter in my direct entry nursing program and my first big snag and it's kind of gotten me down. I don't think she meant to, but the way my clinical instructor responded to one of my questions/ideas really got to me - she basically just made me feel like I was the stupidest person alive. *sigh* Hopefully tomorrow goes better.

[Imafloat, BSN, RN]

Oh, I know my instructors weren't trying to disrespect me or anything - it was a matter of not being able to communicate effectively and then frustration :)

I think I have a better idea now (I think!) I might try and find some exercises to practice with.

I remember my first day at care plans, I was so bothered by it all and confused. I had some similar problems that you describe. I felt my instructor was not hearing what I was saying and I actually felt for a moment like she wasn't taking me serious, which torqued me off and made me determined to figure it out. I studied it out of the textbook and had an aha experience and it has been smooth sailing ever since. I think that is how careplans are, one day it clicks.

I see what you are saying about the impaired mental status, but her impaired skin will kill her before anything else. It could actually be the skin breakdown causing the mental issues, as infections can lead to altered mental status.

Good luck to you, I hope it clicks for you soon.

[Daytonite, BSN, RN]

Jane Smith has double above the knee amputations, is diabetic, obese and confined to a wheelchair. She is very active and often agitated. During her periods of agitation, she waves her arms around wildly and tends to sweat heavily. She has developed a 7cm x 3cm injury to her skin underneath one of her abdominal folds.

Think, for a bit, in terms of the patient's medical diagnoses. She is diabetic. That is a big ticket item. Any chronic disease that wreaks so much havoc on a person cannot be ignored in the care planning process. Her obesity is a contributing factor to the diabetes. Her amputations are complications of the diabetes. Skin breakdown in the abdominal folds is partly because of the obesity and sweating and is a problem because of the diabetes (diabetics don't heal well and are more prone to developing infections). Who knows where the agitation comes from, but it's not as major as the diabetes and skin problem--it's a safety issue more than anything, I feel. The things that the doctors will pretty much pass off to the realm of nurses are the sweating (contributes to the skin fold problem), amputation and confinement to a wheelchair (mobility and safety issues) and agitation (safety issue). There's a lot to care plan for this patient. However, the overall major problem would be the skin condition and/or the diabetes.