Interventions for Care Plan

MendedHeart · Oct 23, 2013

I am having to do my first Care Plan on a case study. I have found my three Nursing Diagnosis and am now working on the five interventions for my number one diagnosis. The fifth intervention that we have to do is a psycho-social intervention and I am not really sure what to do for that one since my #1 ND is Acute Pain. Any help will be greatly appreciated.
What I have so far?
#1 Nursing Diagnosis: Acute Pain r/t TKA AMB pain 7/10, dull and throbbing to right knee, states "pain gets worse when I move."
Interventions:
#1 (Assess): The SN will assess pain to include the location, characteristics, onset/duration, frequency, quality, severity, and aggravating/relieving factors by 1000 on 10/14/13.
#2 (Action): The SN will administer Lortab 7.5/500 mg q4 hours prn and will reassess 30 minutes after administration for effectiveness on 10/14/2013.
#3(Action): The SN will help the patient identify a comfort-function goal by 1100 on 10/14/2013.
#4(Teach): The SN will teach the patient the importance of taking his pain medication to maintain a comfort function goal by 1100 on 10/14/2013.
#5(Psycho-Social): Here is where I am not sure what I need to put
Thanks again for all your help.

Maybe it could be a non-pharmacological intervention psychsocial like diversional activities

What are some diversional activities you could provide in the hospital...we have pet visits, music channels that play very soft music, Chaplain, distractionsetc....

#2- What is the onset and peak of Lortab po? I think you may need to reassess around an hour after admin

#3 I would add to include- using the 0 to 10 pain scale

#4- It is a good idea to Instruct your patient to ask for pain meds when the pain is lower rather than waiting for it to get a 7 then treat it. If the goal is 2 or 3, I would start giving PO meds when the pain is 3-5. Its harder to control the higher it gets and longer they wait.

student_nurse89 · Oct 23, 2013

Thank you for your help

ChipNurse · Oct 24, 2013

Are you using a nursing diagnosis handbook? If not, I would highly recommend purchasing one. This is is the one I used when in school: Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care / Edition 9 by Betty J. Ackley | Barnes & Noble.

nurseprnRN, BSN, RN · Oct 24, 2013

There's also a nifty new book out on evidence-based nursing interventions. They are alphabetical-- and it's a really useful book. Never guess again-- use the approved ones from the Nursing Interventions Classifications (NIC).

Nursing Interventions Classification (NIC),6th edition, Bulechek, Butcher, et al. Elsevier, 2013

Between this and the NANDA-I 2012-2014 you are all gonna ACE your care planning!!!!

MendedHeart · Oct 25, 2013

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick39.html

I didnt have a care plan book, just a lot of texts, and Google. I usually would google the name of the ND and nanda behind it, like " Pain nanda" and usually used the Elsevier one. Its free. All my books were online too except the old ones I got from all my nurse friends. Anyway, Im not discouraging you not to get a book, but until then or your in quick need, the above works for me.

Esme12, ASN, BSN, RN · Oct 25, 2013

The problem is that book is out of date for some of the diagnosis....Nursing Care Plans: Nursing Diagnosis and Intervention by Meg Gulanick PhD APRN FAAN, Judith L. Myers RN MSN and Meg Gulanick (Oct 18, 2002)

nurseprnRN, BSN, RN · Oct 29, 2013

EHS: Nursing Diagnosis Care Plans, 4/e - Pain
I didnt have a care plan book, just a lot of texts, and Google. I usually would google the name of the ND and nanda behind it, like " Pain nanda" and usually used the Elsevier one. Its free. All my books were online too except the old ones I got from all my nurse friends. Anyway, Im not discouraging you not to get a book, but until then or your in quick need, the above works for me.

EEeeek, no, do not do that. There is no such thing as "a nanda." You don't know whether what you're finding is the current work, and "Elsevier" is a publisher, not an author.

OP, if you don't have the NANDA-I 2012-2014 you don't have a nursing diagnosis book. THE nursing diagnosis book, actually, because that's where they originate, and this book gives you the definitive information on related factors, and most importantly, defining characteristics. A 2002 "handbook" has been out of date for, umm, eleven years. And yes, there have been substantial changes in nursing diagnosis since then.

As to needing a psychosocial nursing diagnosis, if you look in the NANDA-I 2012-2014 there are whole sections on coping/stress, comfort, role, and life principles. I don't see students look at those often enough, as they generally prefer the low-hanging fruit of "impaired mobility" and such :), and I am sure that if you peruse them you'll find something that fits the assessment you made of your patient.

MendedHeart · Oct 30, 2013

I never said "a nanda", and I just suggested googling NANDA withe ND, I have found it very helpful to help think and get ideas. I dont see anything wrong with using the internet as long as you make sure its a trusted and official place. I think in nursing school, we can get caught up in writing nursing diagnosis and care plans, yes we need them to teach us how to think and react, but its so different in real life. I think you should get a careplan book, and use other resources too. Google is your friend! Like I said, I am not discouraging!

BTW my source is from 2012 and states it is NANDA

nurseprnRN, BSN, RN · Oct 30, 2013

I know you yourself didn't use the term "a nanda," but I have seen it used here and wanted to head it off at the pass, as it were.

If you are using the actual NANDA-I link, you will discover that they are very specific about NOT giving the entire work and do NOT give the diagnosis, all defining characteristics, and all related factors(Causes). So whether or not your site cites NANDA-I as the source of its information, it is shortchanging you and may well lead to errors-- we see that here all the time.

As to "real life," or what you think that might be after you complete your initial nursing education to qualify you as a beginner, I review medical records for a living in the legal arena and I can tell you definitively that the better facilities do, indeed, use nursing diagnoses in planning nursing care and documenting the thought process that went into doing it (as opposed to task-based, just implement the medical plan of care mindset). When nurses testify as expert witnesses, which we do, we have nursing diagnoses as given by NANDA-I upon which to rely, and this is accepted by the court precisely because it has reliable scientifically-based evidence behind it (google "Daubert Challenge" if you want to know more about that).

So, the faculty are not giving you assignments to teach you how to work with the nursing process and nursing diagnosis to annoy you or waste your time. They are endeavoring to teach you to use something that is critical to your development as a professional. Ignore it or belittle it at your own peril.

MendedHeart · Oct 31, 2013

Hey grntea, not belittling NDs at all, we use them in our care plans at work. I am nurse not a student.

I was just saying it is different, that is all.