HELP!! Trouble writing my Care Plan

meandragonbrett · Nov 3, 2005

Look at everything that is going on with your patient? Take all of their problems and prioritize them using ABC's then Maslow's. You need to get you a good careplan book. I like Ackley's. Look up what's wrong with your patient (say for instance...DVT) You look up DVT in the book and you see that several nsg dx are listed. Choose which one is priority for your patient and that you have the data to support. Once you choose your dx. You need to look up that dx in your care plan book. There will be client outcomes, nursing interventions and rationales, etc. You'll need to pick ones that suit your patient best. Make sure you individualize your careplan for your specific patient.

Christian_SN, RN · Nov 4, 2005

a great book is: nurse's pocket guide diagnoses, interventions, and rationales. 9th edition by doenges, moorhouse, and geissler-murr. this is one on my care plans, not the best one, but i hope it helps you learn.

risk for diagnosis will NEVER have an AEB (as evidence by) but will have an R/T (related to).

example: fluid volume deficient r/t excessive losses through normal routes AEB disrrhea x5 days.

hope this helps you.

assessment and evaluation signs and symt should always go with your Dx. (care plan is not a good example of this)

your outcome should always have a time frame.

goal can be met, ongoing, or not met and give AEB

under interventions: always give a time frame of when to do it. example PRN or per MD orders. your interventions should always match you outcome. if you write for the outcome that: pt verbalizes understanding of Dx then have all interventions that Teach about the Dx.

good luck! you'll get it.

Assessment

Depressed cough reflex, presence of dou tube as of 4/22/2205 at 1100, BD (nutrition) Ensure bolus and medications as ordered by physician, history and complaints of impaired swallowing, inability to clear secretions or any obstructions from the respiratory tact, productive cough with suction as needed, airway is clear at the moment with no vomiting, call light with in reach, HOB elevated to 45 degrees, side rails up x4.

Objective data:

3/11/2005

Patient admit for right sided weakness and impaired swallowing. Refuses to swallow. Patient has decreased gag reflex. Pt will follow commands as needed for procedures.

Nursing Diagnosis

Risk for Aspiration related to reduced impaired swallowing

Desired Outcome

Throughout the hospital stay, the patient will:

Maintian patent airway

Reduce risk for aspiration as a result of ongoing assessment and early intervention. Nursing Intervention

Monitor level of consciousness

Assess cough and gag reflexes

Monitor swallowing ability (cough, clearing, residual, regurgitation, choking)

Elevate HOB to 45 degrees at all times

Check for residual every 4 hours

Explain to care-giver the need for proper positioning

Assess for pocket food

Ticking liquids and medications if sou tube was not in placement for feedings and medications

Turn head to side

Rationale

Increases risk for aspiration

Increases the risk of aspiration

Increases risk for aspiration

Reduce chance of aspiration

High amount of residual indicate delayed gastric emptying and cause distention of the stomach leading to reflux emesis

This decreased the risk of aspiration

Food can get into the throat

To ease swallowing liquids and medication

Evaluation

Depressed cough reflex, presence of dou tube as of 4/22/2205 at 1100, BD (nutrition) Ensure bolus and medications as ordered by physician, history and complaints of impaired swallowing, inability to clear secretions or any obstructions from the respiratory tact, productive cough with suction as needed, airway is clear at the moment with no vomiting, call light with in reach, HOB elevated to 45 degrees, side rails up x4.

Goal Met

As evidence by:

Nurses notes states with observation of patient: patent airway, early intervention and assessment decreased risk for aspiration.

TWilsonRN · Jun 6, 2009

Whenever you need help with nursing Care plans, there's a bunch of samples here:

http://www.pterrywave.com/Nursing/Care%20Plans/Nursing%20Care%20Plans%20TOC.aspx

Daytonite, BSN, RN · Jun 6, 2009

FYI. . .the person who started this thread 5 years ago has not posted to allnurses for 2 years. Don't know if they ever finished nursing school.