I need some help with care plans

[cj29ama]

On Monday I have an exam for 3 Dx: Physical Immobility Impaired, Skin Integrity Impaired and Constipation. For skin integrity I don't know what to assess besides integumentary status and nutritional status. Maybe ROM? Any information about assessments, interventions and outcomes for these 3 would really help me. I'm still in the improving stage and this exam is 10% of the grade.

Thank you!

[trepinCT]

Hey !! Are you NCC?? I have same exam Monday....

[Daytonite, BSN, RN]

if you have a nursing diagnosis book you need to look at the three things from the nanda taxonomy about these diagnoses:

• their definition
  
• their related factors (etiologies)
  
• their defining characteristics (symptoms)

the defining characteristics are going to point you to the direction of what you need to be assessing because you determine a patient's symptoms from assessment information (step #1 of the nursing process). if you do not have a care plan or nursing diagnosis book that has this nanda information, you will find them on these web pages at the very top of each page:

• [color=#3366ff]impaired physical mobility http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=35
  
• [color=#3366ff]impaired skin integrity
  
• [color=#3366ff]constipation http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=13

you can also get assessment information and information about patient conditions from these threads:

• https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)
  
  
• https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
  

please remember that a care plan is nothing more than written documentation of the nursing process. the nursing process is a problem solving method and has five steps which you must follow in sequence. the sequence is an ever-revolving cycle.

1. assessment (collect data from medical record and by doing a physical assessment of the patient)
   
2. nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

wounds are assessed for their size, color, presence of any drainage, odor and staging. see the assessment thread for information on assessing the skin, in general. interventions and outcomes are based upon the abnormal things you find during the assessment.

[cj29ama]

Yes, we are in the same boat :). How do you feel about the exam? I have trouble with the assessments for skin.

[cj29ama]

Thank you very much for your reply! I didn't expect anybody to answer me.

[Daytonite, BSN, RN]

Thank you very much for your reply! I didn't expect anybody to answer me.

Hold your horses! Did you understand what I wrote? Do you have any questions about it? I am truly interested in helping you to understand what you are going to be tested over. I already know this stuff. I'm here to help. Pick my brain.

[trepinCT]

First things first..did you get the rubric that was posted on WebVista?? That is a good place to start..I went to the workshop.Almost didnt go, but decided to at last min and it made a difference. Also keep in mind that these posts are very helpful, but also that different school have different ways of doing care plans. This is what I got out of the workshop:

the example she used was for Fluid volume deficit r/t diarrhea secondary to C.difficile

outcome(must be complete, measurable and time specific): Re-establish fluid balance within 48 hours.

Assessments(4 complete assessments):

1. assess skin turgor

2. check urine output

3.Vital signs

4.check lab data(BUN, creatinine, electrolytes)

Interventions(3 appropriate for nursing Dx)

1.Encourage 1oz.every hour po clear fluids

2.Administer anti-diarrheal meds as ordered by Dr.

3.Maintain strict I & O q8hr

the documentation(Data, Action, Response-use imagination, but be realistic)

be sure to date/time, use past tense(remember, we are documenting "at end of shift")

11-29-07

1200

Data- (remember data is what we found on our assessment, so let assessment be your guide)refused po fluids .Diarrhea(liquid, brown, large amount)x4.Oral mucosa dry.skin turgor poor.vital signs(make something up). Foley drained 200mL concentrated urine.

Action(what we did about what we found- interventions)- provided 1oz po clear fluids q1hr. Administered lomodal at 0800 and 1200 as ordered by Dr.

Response(did it work? she said use imagination, but cannot be unrealistic)

Skin turgor____. Urine output____mL. etc...

be sure to sign name , NCC SN

Good lUCK!!!!

[trepinCT]

P.S. Daytonite is very helpful !!!