Help with Crazy, In Depth Care Plan

[SNLou84]

I posted this below for Daytonite but anyone can respond so I thought I'd post it again so everyone knew that.

Hi everyone! I really need some advice about my care plan. From what I have looked through, I get the feeling my school goes WAY INTO DEPTH with their care plan. I need to put all the Universal Self-Care Requisites down....so Air, Water, Food/Elimination, Activity&Rest, Solitude&Social Interaction, Prevention of Hazards, and Promotion of Normalcy.

Basically I have to put all my vital signs pre and post surgery into this area as well as my assessments for pre and post. I understand that heart rate, respirations, and breath sounds go under Air (Respiratory & Cardiovascular). But where does blood pressure, temperature, O2, and radial pulse go? I have looked online and in my book and I cannot find anything. I think O2 goes under Air as well but wasn't sure. I asked my instructor but he told me I would have to find out for myself. I feel so lost right now. This is my first care plan. Basically this is some of the layout of my care plan.

POWER COMPONENTS. Another area I am confused about. I understand which ones are actual and which ones are potential self-care deficits but we have to write a one or two line statement about each one. So for an example it says:

Attention Span - (for my patient this is an Actual self-care deficit because she is coming out of surgery) - but what would I write for this? "Patient will have a decrease in attention span due to pain medication and anesthesia"???

Because wouldn't that statement then be the same for every one of these (energy level, control of body movements, ability to reasons, etc....) and I know they will not let me put the same reason for why it is actual or why it is potential for every single one. So any other suggestions on what to put would be greatly appreciated!!

Next is the USCR -

Air (resp and cardio),

Water (Renal, F & E)

Food/Elimination (Gastrointestinal)

Activity & Rest (Musculoskeletal & Neuro)

Solitude & Social Interaction ( sensory, perception, and psychosocial)

Prevention of Hazards (Endocrine, Autoimmune, and Chemical)

Promotion of Normalcy (personal hygiene, self concept, reproductive, and integument)

I know I need more things in each category but the only assessment we really did was: listen to the heart (apical), listen to breath sounds, cap refill, bowel sounds, pulses, temp, and watch the O2 monitor, etc) And I don't know if I am suppose to put other stuff in here like her anxiety level, her smoking, her arthritis, etc...

Then we go on to talk about Erickson's stage of development and what I don't understand is it is asking us how the illness affects the clients developmental tasks.......and although she has some ailments, the main thing is her surgery so is that what I am suppose to talk about? How the surgery affects this?? And it asks how the developmental stage impacts the illness? So again, would this apply to the surgery? Because she doesn't really have any ongoing/current illness.

I feel good about half of the care plan but then other parts, our instructor wants it so detailed. I think he just wants to torture us.

After that we have to research the medical diagnosis - we have to explain how the surgery went step by step (which I cannot find online either) and explain it in our own terms which is hard considering it is all so medical. I also have to reference everything.

Then I have to discuss all the meds used - the ones taken at home, the ones given during surgery, and the ones discharged with. As well as any treatments used during surgery like IV's, SCD's, ice packs, etc... We have to explain each med, the dose, route, etc.

Then I have to discuss all the abnormal diagnostic tests she had done as well as ones that turned out normal prior to surgery. I looked through her chart and could only find two tests done.

Then we have to do the PES format of nursing diagnosis, nursing goals/outcomes, nursing interventions, and evaluation. And we have to give multiple goals and interventions for each diagnosis.

And finally, discharge planning with the AMETHOD...which because I didn't get to see her discharged, I have no idea what to write for this....I figure she will go to a physical therapist but I know nothing about diet or meds she would be discharged with.

Any help would be greatly appreciated. At least on the Universal Self-Care stuff and where to put what and what you think is needed for that. Everything else I understand, it's just so LONG and the step by step details for the surgery seems impossible to do in my own words.

Also, there were many things I was not able to find out because I didn't get to see her because she was admitted rather than went home that day.....so I have no idea if she had a foley or what OTC she takes. I never got to look at her full chart before I left for the day because it wasn't finished. So what do I do for this? Do they put a foley in everyone having surgery or only for some surgeries? Would I put NK (NOT KNOWN)....because my instructor said to leave nothing blank.

Any help would be wonderful! Thanks ahead of time!!!!!!!

Lou