Nursing Care Plan

Whispera, MSN, RN · Apr 23, 2009

a few comments...

Outcomes/Goals are generally written: Patient will.... or Staff will... So, you might say "Patient will walk to Albuquerque by discharge date" or Staff will walk with patient at least 20 feet, in the hallway, twice each day, beginning day three of hospitalization." Genereally outcomes are stated for the patient, not the staff.

In the first diagnosis, eliminate the words "old age". It's not needed and may strike the reader as a negative remark. Mostly though, it's not needed. Your second goal...is it you or the patient who will be verbalizing? I'd also limit that middle statement to one thing, such as just "ability to move." In the third goal, are you going to demonstrate use of the walker or is the patient going to show you he/she can do it? You must be specific!

I know this is nit-picking, but we instructors get on your backs to do it the detailed way. Then you remember it when you start doing it on your own, in your heads, if not on paper.

Your second diagnosis sounds good to me, although you could combine the first two parts to something like "inability to put on clothing or shoes."

They're a pain to do, aren't they? But they guide us in what we should do. It's just a way of thinking.

damselham · Apr 23, 2009

whispera, i think (o) means objective data and (s) for subjective data....am i right bmoseyyx3?

carrieprc, RN · Apr 23, 2009

I would break that first diagnoses down to make two. Sounds to me as the patient has had a joint surgery or something??

I would use the first one as Impaired mobility r/t pain from surgery AEB: difficulty moving and unstable gait.

A second diagnoses could be Acute pain R/T surgical incision AEB patient stating "I'm really sore" and stated pain as a 7/10 on the pain scale.

A few goals:

Patient will state pain is a 3/10 within 45 minutes of pain medication administration.

Patient will demonstrate appropriate, independent use of a walker by discharge. (just changed a bit from your one).

And your other goals were good too. I would also go with Patient will...

And maybe a third one too that was always my favorite was Knowledge deficit. There is always something you can teach your patient!!

bmoseyyx3 · Apr 23, 2009

Thanks everyone. =)

Yes the (o) was for objective data and the (s) was for subjective data.

Nursing Care plans are such a pain in the butt! We have to do one every week. =/

I'm going to explain this pts case so everyone can get a better look.

This pt is 82, she is widowed and has 2 children and she lives alone. she had a GB ultrasound on 3/20/09 and their findings were cholelithiasis, common bile duct stones, and renal cysts. She was having RUQ and right flank pain with no hx of trauma, reflux or heartburn. on 3/30/09 she had a laparoscopic cholecystectomy with an intraoperative cholaingiogram. On 3/31/09 she had an ERCP, but it was unsuccessful. She was due to come back on 4/2/09 for a second try. her physical exam was normal except when I was listening to her heart sounds I noticed that she was in atrial fibrillation and her heart rate was 106 but she wasn't on telemetry. She has a history of A.fib, mitral valve disorder, long term use anticoagulant, and hypertension.

As far as labs

RBC, Hemoglobin, hematocrit, platelets, albumin, and calcium were low. INR was a little high.

My instructor also told me to do something on Knowledge deficit, but I just can't think of anything to teach about. She told me to teach about the ERCP but i know nothing about them because we haven't went over that in class.

bmoseyyx3 · Apr 23, 2009

Oh & also, we have to do a pain check q4 hrs and everytime I asked her she just said.."i'm more sore than in pain"

I asked her to label it as a 0-10 with 0 being no pain and 10 being the worst pain and she only labeled it as a 2 or maybe 3.

Whispera, MSN, RN · Apr 23, 2009

Maybe pain isn't the best to use as your focus if her pain is 2-3, unless that's after medication.

It seems something should be included that's related to her cardiac irregularity and history.

If you don't know about ERCP, you should read allll about it. Then you can include it in a knowledge deficit diagnosis and plan. You should always read about your patients' disorders anyway. It makes it real for you and glues it into your brain more than just hearing about it in class will do.

bmoseyyx3 · Apr 23, 2009

I was thinking about doing Anxiety r/t having to come back on 4/2 for second try on ERCP AEB restlessness, pt says, "I wish I didn't have to come back for that ERCP"

& my teacher also told me to do

Readiness for enhanced decision making

she said to do this one b/c she had to make the decision to come back on 4/2. but i don't think that i can make a good nursing diagnosis out of that one.

How does the anxiety one sound?

Whispera, MSN, RN · Apr 23, 2009

I think it's wordy. How about anxiety related to thoughts of possible future surgery....

You can do education in that one. Also, remember, she does NOT have to have the surgery.

Your teacher's suggestion sounds good to me too. It can easily include lots of teaching. Remember that stress can yield learning and change if it doesn't get too intense.

In thinking about this patient, you need to consider what is the most important for the patient's life. What could make a difference in survival or quality of life, now and in the long term. Prioritize. What will lead toward the best possible future and easiest recovery?

bmoseyyx3 · Apr 23, 2009

I think i'm going to do the anxiety one and teach about what they do during the surgery, the anesthesia, the risks, and why they have to be on NPO

& once again, thank you so much. you were a great help!

bmoseyyx3 · Apr 23, 2009

Oh and also

Could I put like teaching the procedure as one intervention

Anesthesia as another intervention

Risks as one intervention

or do them all in one intervention?

I have to have 10 interventions and 3 outcomes/goals

Whispera, MSN, RN · Apr 23, 2009

She's 82 and anxious! Keep the teaching simple. I'd prefer all the teaching as one intervention, but maybe you could do it orally and give a handout? 10 is alot of interventions!