need help with care plan

Editorial Team / Admin · Apr 18, 2012

Hello and welcome to allnurses.com.

We moved your thread to the Nursing Student Assistance forum.

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talo · Apr 18, 2012

Hi

I don't even met my pt yet. I will do it this afternoon, but the instructor wants us to do a NS before.

thanks

Esme12, ASN, BSN, RN · Apr 18, 2012

what is a ns? i think instructors do a disservice to students when they require a care plan before the patient is assessed since the largest component of a care plan is the patients assessment. but, there is nothing i can do about that. i am going to assume that you are first year possibly first semester.

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. you need to know the pathophysiology of your disease process. you need to assess your patient, collect data then find a diagnosis. let the patient data drive the diagnosis.

the medical diagnosis is the disease itself. it is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. it is trying to teach you how to think like a nurse. think of them as a recipe to caring for your patient. your plan of how you are going to care for them.

from a very wise an contributor daytonite.......

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

what i would suggest you do is to work the nursing process from step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

.......check out this link.

https://allnurses.com/nursing-student...is-290260.html

you prioritize your needs according to maslow's hierarchy of needs.

maslow's hierarchy of needs - enotes.com virginia henderson's need theory

maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

self-actualization – e.g. morality, creativity, problem solving. least important
esteem – e.g. confidence, self-esteem, achievement, respect.
belongingness – e.g. love, friendship, intimacy, family.
safety – e.g. security of environment, employment, resources, health, property.
physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis. most important

assumptions

maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

the needs maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
growth needs are the highest level, which is self-actualization, or the self-fulfillment.
maslow suggested that only two percent of the people in the world achieve self actualization. e.g. abraham lincoln, thomas jefferson, albert einstein, eleanor roosevelt.
self actualized people were reality and problem centered.
they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
they tended to be spontaneous and simple.

application in nursing

maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.

Esme12, ASN, BSN, RN · Apr 18, 2012

now what do you know .......

l buttocks cellulitis r/t self injections i&d and packing in place. can you help me with a care plan. pmh dm ; meds include insulin ss, zosyn

we know the patient has cellulitis and is post operative, i/d with packing.

what is cellulitis? (cellulitis: medlineplus medical encyclopedia) the term cellulitis is commonly used to indicate a non necrotizing inflammation of the skin and subcutaneous tissues, a process related to acute infection that does not involve the fascia or muscles and that is characterized by localized pain, swelling, tenderness, erythema, and warmth.

cellulitis was classically considered to be an infection without formation of abscess and without purulent drainage or ulceration. in clinical practice, the division between cellulitis and abscess is not distinct. frequently, the macular erythema of cellulitis coexists with nodules, areas of ulceration, and frank abscess formation. medscape: medscape access (you have to register but it is an excellent reference and free)

the patient is diabetic. what is diabetes? what are the complications of diabetes? diabetes complications: medlineplus even though this article is for foot cellulitis many of the factors remain the same.....complications of cellulitis medscape: medscape access does this patient need education about how to avoid complications in diabetes? diabetes care: 10 ways to avoid diabetes complications - mayoclinic.com is the patient compliant? how old is this patient?

the patient is post op. what would you look for an a post op patient. pain? fever? redness? what drainage is coming from the wound? what are the patient's vitals? is th4e patients pain being relieved? will you need to teach the patient to care for drsg at home?

you need a good care plan book. i prefer gulanick: nursing care plans, 7th edition. they have an online care plan constructor. it used to be free but they caught on so now you need to buy the book to use the constructor.

care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and trto fit the patient into diagnosis. here are some useful care plan sited with examples to follow

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pd

i hope this helps.