I really hate care plans...can someone help me?

jelrtLPN · Oct 8, 2005

First I think your careplan is good. Second i hated careplanning too. Third, when i was in nursing school, going through it with a girlfriend of mine, Christmas came and she gave me the most wonderful gift. A CARE PLANNING BOOK...... you can buy them at any book store. They have wonderful plans in there and great ideas to subsidize your own....Good Luck!!!

:roll

MIA-RN1, RN · Oct 8, 2005

Ok so i am doing a care plan on Pain(chronic)...I cant think of interventions and I think my goals need to be better...can someone please help?
Nursing Diagnosis: Pain (Chronic) related to malignant neoplasm of lymph, head, neck and floor of the mandible.
Manifested by:
a.Client crying when asking for pain medication.
b.Client rating pain a 9-10 on a scale of 1-10.
c.Client asking for pain medication before it is due.
Desired Goal: Pain will decrease to a 4/10 or lower on a 1-10 scale after medication is administered.
a.Client will rate pain a 4 or less on 1-10 scale.
b.Client will be in a relaxed state of mind, by smiling and doing hobbies she enjoys, such as reading.
c.Client will have no visible of pain relief such as grimacing.

We have been taught that our outcomes need to be SMART--Specific, Measurable, Attainable, Realistic and Time-bound. So I would reword your goal a bit--instead of after medication is administered, which is not specific to time, I might say "Patient will report pain level as 4/10 or lower on a 1-10 pain scale one hour after receiving pain medication." You have a specific outcome, measurable with the pain scale, attainable because pain relief is what you expect, realistic because it makes sense that pain will decrease, and time-bound because you gave the time you will re-assess. (It might be 30 minutes, depending on your agency policy) Also, because pain is subjective, you want the outcome to include subjective information, that's why you will say "Patient states".

Also, I have been taught not to use a medical diagnosis in the 'r/t' part of the diagnosis, so for your patient you might want to reword your dx to say something like Pain, Chronic r/t Chronic physical disability secondary to malignancy of lymph, head, neck and floor of the mandible.

You also might check to see if Acute Pain is more realistic than Chronic. My reasoning being that For Chronic pain you want to look at more long-term goals such as takes preventive measures, recognized factors that increase pain etc. Of course, if your patient has had this dx for a while, then Chronic fits. If its a new dx related to a treatment or surgery or something, Acute might fit better, depending on the rest of your pt circumstance.

As for interventions, just think for a minute what you might do to help someone. First of course you give the pain medicine. What else can you do while you wait for the med to take effect? Its very easy to think too hard and trip yourself up. What would you do for yourself? Would you adjust your position to a more comfortable position? Would you distract yourself with a book on tape or some music? Would you love someone to give you a theraputic backrub? (hints hints)

Do you have a diagnosis book? If you don't, I recommend one. I use mine ALL THE TIME because it shows not only dx's but outcomes, interventions, etc. I use Ackley and I also have one by Judith Wilkinson that I love cause it's smaller and fits in my pocket.

You are definitely on the right track here, its mostly wording to work on. Good luck! :)

Disclaimer--still a student myself. Graduating in May 06

Fox · Oct 9, 2005

Can you post the ISBN for the books?

Thanks

We have been taught that our outcomes need to be SMART--Specific, Measurable, Attainable, Realistic and Time-bound. So I would reword your goal a bit--instead of after medication is administered, which is not specific to time, I might say "Patient will report pain level as 4/10 or lower on a 1-10 pain scale one hour after receiving pain medication." You have a specific outcome, measurable with the pain scale, attainable because pain relief is what you expect, realistic because it makes sense that pain will decrease, and time-bound because you gave the time you will re-assess. (It might be 30 minutes, depending on your agency policy) Also, because pain is subjective, you want the outcome to include subjective information, that's why you will say "Patient states".
Also, I have been taught not to use a medical diagnosis in the 'r/t' part of the diagnosis, so for your patient you might want to reword your dx to say something like Pain, Chronic r/t Chronic physical disability secondary to malignancy of lymph, head, neck and floor of the mandible.
You also might check to see if Acute Pain is more realistic than Chronic. My reasoning being that For Chronic pain you want to look at more long-term goals such as takes preventive measures, recognized factors that increase pain etc. Of course, if your patient has had this dx for a while, then Chronic fits. If its a new dx related to a treatment or surgery or something, Acute might fit better, depending on the rest of your pt circumstance.
As for interventions, just think for a minute what you might do to help someone. First of course you give the pain medicine. What else can you do while you wait for the med to take effect? Its very easy to think too hard and trip yourself up. What would you do for yourself? Would you adjust your position to a more comfortable position? Would you distract yourself with a book on tape or some music? Would you love someone to give you a theraputic backrub? (hints hints)
Do you have a diagnosis book? If you don't, I recommend one. I use mine ALL THE TIME because it shows not only dx's but outcomes, interventions, etc. I use Ackley and I also have one by Judith Wilkinson that I love cause it's smaller and fits in my pocket.
You are definitely on the right track here, its mostly wording to work on. Good luck! :)
Disclaimer--still a student myself. Graduating in May 06

MIA-RN1, RN · Oct 9, 2005

Can you post the ISBN for the books?
Thanks

Sure!

"Nursing Diagnosis Handbook; a Guide to Planning Care" 6th edition c 2004

By: Betty J Ackley and Gail B. Ladwig

published by Mosby

ISBN 0-323-02551-X

"Nursing Diagnosis Handbook" 8th edition c 2005

By: Judith M Wilkinson

Published by Pearson Prentice Hall

ISBN 0-13-04936708

They are both great, I use them both about the same. Ackley is a little better if you are just starting out.

truern · Oct 9, 2005

I agree with the poster that mentioned your r/t is actually a medical diagnosis....it needs to be something like r/t soft tissue damage secondary to cancer...., or r/t inflammatory process secondary to cancer of the.....

Our goals have to be specific, time-limited, etc as well...

Also, this sounds like acute pain...goodness knows, I'd hate to think someone has chronic pain of a 9-10/10 daily