Help with BIG careplan!

P B and J · Feb 19, 2012

I can help with the aeb. Your evidence is the objective and subjective data from your assessment, the chart, lab results etc. that point to your diagnosis. For example: Ineffective airway clearance r/t blah blah aeb O2 sat 88%, patient statement "I can't catch my breath", etc. etc.

Long term goals are just that. Long term. If her treatment is successful, how will you measure that success? What goals would she reach? It doesn't matter if the attainment of those goals are in the hosp, in long term care, or at home. If you are unable to evaluate because you won't be there to evaluate, say so: Unable to evaluate. Would have expected JD to meet goal by being able to blah blah blah by 03/01/12 at 1400. Just remember your goals have to be measurable, and your evaluation, if you are unable to evaluate, should show how you would have measured her success.

Hope I helped :) Good luck!

Blue Cat · Feb 19, 2012

Do you have a nursing diagnosis book? I found Ackley's to be the best for me, but I would start there.

When I had a similar patient in clinical last semester, my instructor had me focus on her renal failure and build my priority nursing dx around that rather than her admitting dx. So I would use fluid volume excess (aeb edema, crackles in the lungs, altered mental status, etc). In my program we had to use a Maslow's Hierarchy of Needs worksheet and enter all the abnormals (labs, meds, vital signs, etc) and those would be the AEB that you plug into your nursing diagnosis statement.

The nursing diagnosis book will have goals that you can use, but they don't have to be long term. They can be goals for during your shift or for the duration of the patient's stay.

Hope that helps,

Blue

Esme12, ASN, BSN, RN · Feb 19, 2012

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories.

i can not take credit for this.....this was written by a beloved member daytonite (rip) please go to this link there is plenty of information. https://allnurses.com/general-nursing...ns-286986.html

care plan reality:

the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

what i would suggest you do is to work the nursing process from step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

care plan reality:

nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. they are all linked together with each other to form a nice related circle of cause and effect.

you really shouldn't focus too much time on the nursing diagnoses. most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. the nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.