Need some help with care plan

Trauma Columnist · May 24, 2012

Can you show us what you have first?

Esme12, ASN, BSN, RN · May 24, 2012

welcome to an! the largest online nursing community!

we are happy to help but we won't do it for you . you show us what you have so far and we will lead you in the right direction adjust correct any mistakes you have as well as research/point you to where you need to get your information.

care plans/care maps/case studies/teaching 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 them to their previous level of life or to make them the best that they 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.

a teaching plan starts like you do for any care plan. . .from me and the words of a dear friend/contributor daytonite (rip)

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)

a physical assessment of the patient
assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

care planning is determining what the patient's problems are. in this case, you specifically know you want to focus on his nutrition. so, you need to do an assessment of his diet and nutritional state. i have no specific assessment guide for that, but i assume you do. you are looking for abnormal data because the abnormal data will become the evidence that will support the nursing diagnosis that you will use.

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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

your instructors might have given it to you.
a book that contains the nanda-i nursing diagnoses
many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis. i like ackley: nursing diagnosis handbook, 9th edition and gulanick: nursing care plans, 7th edition
the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
or your text books.i also love emedicine/medscape http://emedicine.medscape.com/
medscape nurses http://www.medscape.com/nurses

medscape is absolutely free and requires registration. it is a great resource and sourse of information.

there are three ways to introduce teaching interventions. either through a diagnosis that focuses on the patient's nutritional problem, using the deficient knowledge, specify diagnosis or ineffective health maintenance diagnosis. each diagnosis has different etiology and evidence to support it. i suggest that the patient's attitude toward this will have a strong affect on which diagnosis you end up using out of the three and how your teaching plan will be focused.

a formal written teaching plan has these components:

overview: a synopsis about what is going to be taught in the course
goal(s): the aim(s) or outcome(s) that you want your learner to achieve as a result of the lesson you plan
objectives: the more specific information that the learner will come away from the course knowing that will achieve the goal(s) you have determined.
content: a play-by-play of the specific content that is going to be taught and in the sequence it will happen. your content should address and cover all the objectives. this part of the written lesson plan is presented in an outline format.
procedures and materials: how all the above will be achieved, i.e. lecture, demonstration, discussion, etc. materials that can be used and resources that can be needed for the lesson to be successful and essential to teaching your lesson plan are listed and may include demonstrations, audio-visuals, handouts, experiments, stories, game playing and any number of other creative items.
evaluation: determining if you met the goals of the teaching plan. this can be done through a return demonstration, short post test, short question and return answer session with the client to verify they understand the information correctly or a task the participant needs to perform.

for more information on care planning from our beloved daytonite see https://allnurses.com/florida-nurses/teaching-patient-care-345471.html https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans

now you must adjust this to the age of your child according to erickson's growth and development

Esme12, ASN, BSN, RN · May 24, 2012

[TABLE]

[TR]

[TD][/TD]

[TD]Basic Conflict

[/TD]

[TD]Important Events

[/TD]

[TD]Outcome

[/TD]

[/TR]

[TR]

[TD]Infancy (birth to 18 months)

[/TD]

[TD]Trust vs. Mistrust

[/TD]

[TD]Feeding

[/TD]

[TD]Children develop a sense of trust when caregivers provide reliabilty, care, and affection. A lack of this will lead to mistrust.

[/TD]

[/TR]

[TR]

[TD]Early Childhood (2 to 3 years)

[/TD]

[TD]Autonomy vs. Shame and Doubt

[/TD]

[TD]Toilet Training

[/TD]

[TD]Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.

[/TD]

[/TR]

[TR]

[TD]Preschool (3 to 5 years)

[/TD]

[TD]Initiative vs. Guilt

[/TD]

[TD]Exploration

[/TD]

[TD]Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt.

[/TD]

[/TR]

[TR]

[TD]School Age (6 to 11 years)

[/TD]

[TD]Industry vs. Inferiority

[/TD]

[TD]School

[/TD]

[TD]Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.

[/TD]

[/TR]

[TR]

[TD]Adolescence (12 to 18 years)

[/TD]

[TD]Identity vs. Role Confusion

[/TD]

[TD]Social Relationships

[/TD]

[TD]Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self.

[/TD]

[/TR]

[TR]

[TD]Yound Adulthood (19 to 40 years)

[/TD]

[TD]Intimacy vs. Isolation

[/TD]

[TD]Relationships

[/TD]

[TD]Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.

[/TD]

[/TR]

[TR]

[TD]Middle Adulthood (40 to 65 years)

[/TD]

[TD]Generativity vs. Stagnation

[/TD]

[TD]Work and Parenthood

[/TD]

[TD]Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world.

[/TD]

[/TR]

[TR]

[TD]Maturity(65 to death)

[/TD]

[TD]Ego Integrity vs. Despair

[/TD]

[TD]Reflection on Life

[/TD]

[TD]Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.

[/TD]

[/TR]

[/TABLE]

http://psychology.about.com/library/bl_psychosocial_summary.htm

Esme12, ASN, BSN, RN · May 24, 2012

Psychosocial Stage 4 - Industry vs. Inferiority

This stage covers the early school years from approximately age 5 to 11.
Through social interactions, children begin to develop a sense of pride in their accomplishments and abilities.
Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their ability to be successful. Erikson's Psychosocial Stages - Preschool, Middle Childhood, and Adolescence

Psychosocial Conflict: Industry versus Inferiority

Major Question: "How can I be good?"
Basic Virtue: Competence
Important Event(s): School

Industry versus inferiority is the fourth stage of Erik Erikson's theory of psychosocial development. The stage occurs during childhood between the ages of six and eleven. School and social interaction play an important role during this time of a child’s life. Through social interactions, children begin to develop a sense of pride in their accomplishments and abilities.

During the industry versus inferiority stage, children become capable of performing increasingly complex tasks. As a result, they strive to master new skills. Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their ability to be successful.

According to Erikson, this stage is vital in the development of self-confidence. During school and other social activities, children receive praise and attention for performing various tasks such as reading, writing, drawing and solving problems. Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.

Industry Versus Inferiority - Stage Four of Psychosocial Development

http://www.emedicinehealth.com/type_1_diabetes_children_living_with_the_disease-health/article_em.htm