HELP!!! My careplan is due tomorrow @ 6am!!!

[krjacobs07]

Hi everyone i hope I can get an answer ASAP. Now regarding my title....To make a long story, longer.

I have been given the pleasure of creating a care plan WITHOUT first being taught how to put one together and less than a day deadline to turn the careplan in.

My first careplan I did was a total BOMB....Wrong, wrong, worng, wrong, wrong

Same situation last week

Just notified to have one done the next day

I had no clue you even had to have a careplan book to assistance with creating a careplan (this is just how much out the loop us students have been since the start of the nursing program)

Well I found this website and now I'm asking for help.

My pretend patient is a paraplegic due to osteomyelitis and diskitis, huge sacral wound with a rectal tube, colostomy and foley. She is AAOx3, Older pt is 60. Admitted for sepsis and have Hx of HTN, renal failure (gets dialysis), DM II, Anemia, Hypothyroidism and is always finding ways to get OOB knowing she is on CBR

ND: Risk for fall r/t immobility AEB no active ROM of lower extremeties

Pt will:

STG: Experience no fall this shift

LTG: Verbalize ways to prevent a fall by the time of discharge

STG Interventions and rationale I did pretty great on but for my LTG I'm clueless

I did one for my LTG stating: Involve pt in identifying ways to prevent a fall every shift

Rationale: Empowers the pt to take and active role in her own healthcare

Since it's the beginning of careplans she want it simple and basic

I must document where I get my info from so offering different websites to go to would help greatly

1 stg 1 lgt 4 interventions for each goal and rationale.

Thanks for the help

Nursing Student in Help!!!!!

[racquetmom]

Did you do careplan search on here as there are many websites to go to and how to do this from Daytonite. I haven't started so I am of no help except that I have seen numerous posts on this subject with websites to go to.

[krjacobs07]

Thanks I'll do that

[9livesRN, BSN, RN]

hi there! let me humbly try to help with the little i know:

my pretend patient is a paraplegic due to osteomyelitis and diskitis (does anxiety play a role on her behavior? its a psychosocial nanda and teachers love them), huge sacral wound with a rectal tube, colostomy and foley. she is aaox3, older pt is 60. admitted for sepsis and have hx of htn, renal failure (gets dialysis), dm ii, anemia, hypothyroidism and is always finding ways to get oob knowing she is on cbr(i will raise the flag for anxiety again, some times its hard for you to speak with people when they are anxious, they need to be talked to in a calm manner, short simple sentences and without information overload. need to find why she is anxyous so that you can help? is it related to impaired mobility? or maybe knowledge deficit related to her diagnosis?)

nd: risk for fall r/t immobility aeb no active rom of lower extremeties (the rom could be one of your goals, where you would communicate with the healthcare team in order to assist her with her exercises, you could even help! and make this acheaveble by the end of your shift)

pt will:

stg: experience no fall this shift ( this is good) (place the call light within reach, night stand, water and everyhing else!)

stg: prevent skin breakdown (she cant help to move her self q2h so you can assist her, so your stg would be prevent skin break down by assisting the patient with position changes q 2 hours)

related to her anxiety: another stg would be use of therapeutic communication in order to decrease patient anxiety

as a bonus throw in something on patient education, teachers love them, and as nurses we do patient education every day. something like dm reinforcement, or nutrition regarding her renal disease, or the patient will state 2 fall prevention messures by the end of my shift... or even regarding infection prevention, hand washing!

ltg: verbalize ways to prevent a fall by the time of discharge (this is good) but remmember other things like her skin break down, or the fact tha she has a big'ol wound, so maybe you could use something else like, patient will understand measures of infection control, diabetes control, patient will ask to be turned every 2 hours to prevent skin break down,

so you could say something like

ltg, patient will request all health care providers to perform hand washing prior to providing care to her in order to prevent infection. (something easy that she can do and will actually be quite helpful forever)

stg interventions and rationale i did pretty great on but for my ltg i'm clueless (i would throw in another intervention is to keep her clean, monitor the rectal tube for drainage, to prevent further implications such as skin breakdown or further infections)

i did one for my ltg stating: involve pt in identifying ways to prevent a fall every shift

rationale: empowers the pt to take and active role in her own healthcare

since it's the beginning of careplans she want it simple and basic

i must document where i get my info from so offering different websites to go to would help greatly

1 stg 1 lgt 4 interventions for each goal and rationale.

thanks for the help

nursing student in help!!!!!

hope it helps a little!