Help with my first Care Plan

Esme12, ASN, BSN, RN · Oct 9, 2013

This is general information about care plans.....

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

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: ADPIE

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)

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.

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: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Esme12, ASN, BSN, RN · Oct 9, 2013

The neonate is different....what are the complications to premature birth? Was this a vag delivery? Is the baby breast fed? How is Mom? is this her first pregnancy? Is the baby alert? Is it feeding well? Is the baby male? Was he circumcised? What about the babies umbilical cord?

If the babies skin still yellow...the baby still has jaundice...maybe not enough for the lights nut the baby still is jaundiced....wht would you do? wht does this put the baby at risk for? What was the babies birth weight?

NicuGal, MSN, RN · Oct 9, 2013

Jaundice/hyperbilirubinemia is related to prematurity. And yes, once lights are turned off you check a rebound total bili within 24 hours. An easy way to figure out light level on a preemie less than 35 weeks is take the birthweight in grams, divide by 2 and the first two numbers are your light level. What interventions would you consider? How is the bili removed from the body after the lights break it down? How would you educate the mom? What safety things are in place?

If mom is diabetic what other risks are there for the infant? Look up IDM and premature infants. They have added risks and may have blood sugar problems, are notorious poor eaters ( although at 32 weeks he would probably be on IVF and ng feeds as they usually aren't interested in eating until closer to 33-34 weeks).

Lots if things to work with, neonatal hyperbili ( he is jaundiced, he doesn't have jaundice), nutrition, adaption to extra uterine life.

futureTBA · Oct 9, 2013

Thanks Esme! I've seen you post this before and it's the only reason I'm close to completing a care plan :)

I decided to go another route. We were not really told how to go about this, and it's based on a child that I've already spent the day with and won't see again. Unfortunately, we don't go in for our assignment the day before, which is too bad because I think I'd like to try putting a care plan into place and following it.

Anyways, here's what I have (bearing in mind we don't have to pick the most important, just any nursing diagnosis).

Twin B

Assessment:

Infant born 4 days ago

lady partsl birth (twins), transverse presentation, vacuum assisted extraction

Estimated Gestational Age: 33 weeks 2 days

Birth weight 2155g (4lbs 12oz)

APGAR scores at 1 and 5 mins were 8 and 9

Mom experienced premature rupture of membranes at 30 weeks. Celestone administered twice. IV antibiotics as well.

Mom has history or IDDM, hypothyroid and low platelets

Twin B is being fed formula by NG tube

Was started on IV antibiotics after birth and these were discontinued on day 3

Jaundice was confirmed through elevated bilirubin levels and phototherapy was done (d/c before I saw the baby)

Bili levels were:

futureTBA · Oct 9, 2013

Sorry, it cut me off.

Bili levels were:

Day 1 108

Day 2 (am) 103

Day 2 (pm) 89

Day 3 108

On the day I was caring for Twin B his vitals ranged quite a bit

HR 125-165

RR 16-62 (irregular)

T 36.8C - 37.2C

We transferred him from the isolette to the crib that morning.

Here's what I have for my care plan so far:

Risk for imbalanced body temperature r/t premature birth, low birth weight, reduced levels of brown fat due to prematurity, recent transition from isolette.

Outcomes: Infant will maintain temperature within normal range of 36.5C - 37.2C during shift.

Interventions: 1. Infant to remain dressed in gown and hat 2. Crib to be placed away from any source of draft (doorways/vents) 3. Blanket placed over top third of crib (taped to edge of crib to prevent dropping onto baby's face) 4. Axillary temperature to be monitored Q3h and prior to any care

Thoughts?

futureTBA · Oct 9, 2013

Hi NicuGal! I wound up going with imbalanced temperature given his low birth weight and prematurity. But I'm happy to think this one through.

So, the phototherapy was complete. The bili levels should have been taken the day I was there (although they might have been with the lab and just not up yet).

Bilirubin is excreted through the feces, so I know we checked his diaper every three hours before his feedings. I did his diaper change twice and both times he had a transitional stool, nearly milky. So it looked like he was probably excreting the excess just fine. I would explain to the parents that feeding should occur every 2-3 hours to help pass the bilirubin through and that if he was getting more jaundiced rather than less after discharge from the hospital, he should see his paediatrician as soon as possible.

Esme12, ASN, BSN, RN · Oct 9, 2013

NICU gal is your resource...this is not my area of expertise.

But I agree...... temperature regulation is immature in all babies let alone a premie twin.

NicuGal, MSN, RN · Oct 9, 2013

Very good! I am kinda nerdy... I love NCPs lol. But with the back to sleep initiative, no blanket over the top of the crib, even taped. The hat should be sufficient :)

futureTBA · Oct 9, 2013

Thanks! I've now moved on to the mother half of the care plan. This one is going a little easier :)

futureTBA · Oct 18, 2013

Thanks NicuGal for all the help - I just got my feedback yesterday during my last clinical. My instructor actually asked me to email her my care plan (they were submitted in hardcopy) so that she could use them as examples for future clinical groups :)

I'm so pleased. And I think I might have the same nerdy tendencies you do, 'cause once I got the hang of it, they really weren't that bad. It's just about thinking it through.

(Oh - and I'm glad you picked up on the blanket over the crib. The nurses in the Special Care Nursery were all doing it so I thought it was protocol but managed to find the back to sleep info and realised it wasn't.)