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help with care plan

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by nadomel nadomel (New Member) New Member

2,486 Visitors; 62 Posts

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hi i need some help , i am trying to do a care plan for a patient, she is at 37 weeks and she had spontaneous rupture of membrane , she also has endometrosis , leep and she is positive for hbv . with her first child she had an episitomy . i came up with two nursing diagnosis

1. risk for infection related to spontaneous rupture of membrane as evidenced by vaginal examinations.

 

i am told to give contributing factors and clinical manifestations

  • i identified wbc elevated
  • spontaneous rupture of membrane

 

  • chronic pain related to inflammation and adhesion of endometrial tissue as evidenced by patient reporting pain as 7 on a scale of one to ten and requesting epidural

    • patient has endometriosi

i am trying to come up with short term and long term goals. i identify a long term goal for the second diagnosis as

upon discharge, the patient will lean to manage her pain effectively with the use of pharmacological and non-pharmacological pain relief strategies. some how i don't think this is right

short term goal

1. patient will verbalize understanding of the disease process, diagnosis. management, treatments and resources for endometrioses

 

2. the patient will be able to recite at least 2 ways of managing pain by the end of the day.

 

 

i am stuck i don't even know where to start for the other one .

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Double-Helix has 6 years experience and works as a Nurse, Children's Hospital.

5 Likes; 40,992 Visitors; 3,375 Posts

1. Your first diagnosis is a risk diagnosis, so it should not include the "as evidenced by" section. So your diagnosis should read: "Risk for infection related to vaginal examinations post rupture of membrance.

Now, think about your goals for this patient- what do you want the patient to be able to do or what do you want the patient's condition to be related to infection? If the patient is at risk for infection, what is your goal? I'll give you a hint- you do not want the patient to develop an infection.

Does the patient already have elevated WBCs? (if they do, you do not have a risk diagnosis, you have a possible diagnosis) Or is that something you would look for? Fever is also another possible indication of infection.

2. Is the pain chronic or acute? Chronic means she has had pain for longer than three months. Is this the case? Otherwise it is acute pain. Also, what is really causing her pain? Is it the endometriosis, or is it the labor? You did great describing the problem of endometriosis, but is that what she wants an epidural for?

Likewise in your clinical manifestations and contributing factors- is endometriosis appropriate here? How is her pain manifesting physically? Is she tense, grimacing, moaning, have high blood pressure, high pulse? These are clinical manifestations.

Your long term goal- be careful using the word "learn." Is your goal for the patient to learn, or for the patient to know ways to manage pain? And how can you assess if she knows? Because she states ways to do this.

Short term goal: 1. I don't really think that this goal is related to pain. Also, is this realistic? This seems like a lot of information for the patient to know. Consider cutting back to what is really important for the patient to know.

Goal numbe 2 is fine.

Hope this helps. PM me with any more questions.

Ashley

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2,486 Visitors; 62 Posts

Can u send me your email address i will send you a microsoft word document . thanks for responding

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Double-Helix has 6 years experience and works as a Nurse, Children's Hospital.

5 Likes; 40,992 Visitors; 3,375 Posts

Sorry, but why do I need a word document? I am willing to offer some advice and suggestions, but I am not going to do your care plan for you.

Edited by Double-Helix

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2,486 Visitors; 62 Posts

Actually I did not want u to do that I just wanted to show u the proper format that I had . because i could not copy it properly on this venue. I did not want u to tell me the answer. I just wanted to know if I am on the right track.

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Double-Helix has 6 years experience and works as a Nurse, Children's Hospital.

5 Likes; 40,992 Visitors; 3,375 Posts

Okay. As a general rule, I don't give out my email to people over the internet, unless I know them personally. I don't think I could help with formatting anyway. Nearly every school uses a different care plan format. My school used three. I think the important parts- the wording of your diagnoses, the goals, etc. came through fine.

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2,486 Visitors; 62 Posts

Okay thanks for your help I really appreciate it .

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