Need help with my very first careplan.

  1. Hey all. So everyweek we are to pick our careplans up and our instructor will be there in the Am to help guide us, however this week a friend of hers had an emergency so she said we would have to do it on our own. These are not being graded and she also said she will be lenient since they are our first and without her help, but I still want it to be just right. So i went to the hospital VERY early this morning and got all the info I think I will need, some of the nurses were very helpful. I was cut a little bit short because i ran into a shift change, but I believe i have everything I needed, and if not I can return monday night. My careplan is due Tuesday am, which is my clinical day. Our teacher gave us a template to complete, Im just really confused altogether. For the 1st 2 weeks we have a partner, I was assigned the meds portion of the careplan. I have all the meds the patient will be taking, the allergies, baseline blood tests, and vital signs takne over the past couple days. They were admitted yesterday, because of an accident where they fell at home and fractured their hip. They are due to be getting surgery Tomorrow march 5th, and I will be taking care of them Tuesday the 6th along with my partner. I just am completely lost when it comes to filling out the careplan. I have filled out the obvious, such as their room number, allergies, and activity:bedrest. They were also given no advanced Directives. However it asks for the documented code status, which I didn't understand. She has no food allergies or specific diet, however it did say she needs 2 grams sodium diet. and than it also asks for recommeneded Diet for this disease process, which im assuming is normal? because we will be getting her post-surgery??
    It than asks for primary medical diagnosis? would i write L FX hip?
    Other related/underlying meidcal problems/Diagnosis: I have that they have had surgery in both eyes for cataracts with no date available, and she has also had melanoma removed in the past. She also suffers from a detached retina, and osteoperosis.
    Surgical or Invasive Procedures and Dates (if applicable): Not sure what exactly they want me to write here because I was given no dates for the catarcats surgery and her hip is being operated on tomorrow, would I write that in? Because I know im not suppose to document something before its done. And there were no documentation in the xray portion of the folder, but the nurse told me that she was going to have them later today.

    Heres the section I'm mostly confused about.
    Explanation of Diagnosis, Surgery, and/or procedure.
    The reason Im so worried about it is there is so much space. And i dont even know where to begin. We know she has a fractured Left Hip and it is being operated on tomorrow, other than that I'm not sure what they want me to say. From some of the meds she is taking the nurse says it looks like anxiety related problems as well and she has refused one of the medication but I could not read the writirng for the life of me.
    I think I have the meds portion down, just the meds she is taking and I will fill them out according to my drug book and make them patient specific.
    I also think I am okay in the Labs/diagnostics section: I plan to write her baseline findings, and I have the implications written in.

    Now my partner is responsible for the Nursing Diagnosis and process, goal setting and what not. However we plan to collaborate and type it all up tomorrow night and I'm sure he is just as nervous and confuised as I am. I know we will be using the NANDA list, Im just confused as to what? and im not good at the format in which they are to be said.
    At risk for falls as r/t and evidenced by?
    Impaired mobility:bed as r/t and evidenced by?
    Im guessing she'll be on Morphine as well as Percocet so can i still say Acute pain r/t surgery and evidenced by facial cringes?
    What else could bve a diagnosis? Maybe self care deficits?

    I Just dont know where to begin either with the Nursing Process, numbering her problems in priority, making goals and outcomes and nursing interventions. What are some things I can do as an adn to help her, some daily or short term goals that are measurable, I will only be with her this one time, And i know she wont be able to move? The only thing I can think of is rotating her q 1-2 hours? What else can I do to help and ease her progess?

    Thank you to all and any of you who take the time to read this and to help me out, I really appreciate it!!
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  3. by   labman

    First for you is to take a deep breath. Hehe

    Ok on surgery dates if there is none listed except the hip replacement put that one down. Some people are just that lucky!

    And with how to prioritize remember the A,B,Cs. Lets start with airway. Post surgery would there be any airway issues (maybe ineffective airway clearance) next would be breathing issues any of them there??, C- circulation issues anything with her heart (maybe bed rest ineffective tissue perfusion if you do not roll her enough). I think then D is saftey or pain. Surgery would there be pain? With goals and outcomes I just look in the book and use kind of the generic one from the book (a med surg nursing one or a nursing diagnosis book) anymore questions just post again. I hope this helps. Trust me it gets A LOT easier as you go on.
  4. by   Daytonite
    hi, autopsy. . .let me start by helping you with some of your questions you need to fill out on your template. the "documented code status" refers to what is to be done if the patient has a cardiac or respiratory arrest and whether or not the patient has a "do not resusitate" order. the doctor has to specifically write out such an order. if there is no such order, i would write the word "full code" in that space which would indicate that if the patient has a code blue all efforts will be made to save the patient. with a "do not resusitate" (dnr) order, no cpr is done and patient would be allowed to die naturally if they suffered a cardiac or respiratory arrest.

    when a patient is just returning from general anesthesia their diet will be npo at first until nausea has passed. then, depending on the type of surgery, they will be started on clear liquids. if they can tolerate clear liquids without nausea or vomiting, they are advanced to full liquids and finally to a regular diet. by the time you have the patient on her first full day after surgery, she should be advanced to a regular diet if she had no problems with liquids the day of surgery. her diet should go back to being the same diet she was on when she was admitted. patients with osteoporosis are usually advised to include more calcium in their diets. you might want to do a little more research on that.

    it sounds like her primary diagnosis is the fractured hip. a primary diagnosis is the chief complaint for which the patient is being treated or for which the person seeks medical care. the fractured hip is it.

    for your other related/underlying medical problems/diagnoses just write the following: bilateral cataracts, history of melanoma of unknown site, history of detached retina and osteoporosis.

    for surgical or invasive procedures and dates (if applicable) write bilateral cataract extractions of unknown date, repair of detached retina of unknown date and probable excision of melanoma of unknown site and date. x-rays are not invasive procedures. invasive procedures refer to instruments that are taken inside the body or through the skin or other orifices to treat or examine the patient. most simple x-rays are non-invasive procedures. much of this information should be explained in the doctor's history and physical exam. if it wasn't present in the chart when you reviewed it, it will be there when she goes to surgery or the or nurses will have had a hissy fit, i guarantee it.

    the section for the explanation of diagnosis, surgery, and/or procedure is where they want something about the pathophysiology of the disease (or in this case), injury, and the medical treatment that will be applied to treat it. to complete this part you need to hit the books--a pathophysiology book, if you have one. look up "fractures" and what the process of a broken bone entails. how does a bone heal? what will be done by the surgeon tomorrow in surgery, a hip pinning or a total hip replacement? did the chart say that? it would have been in the doctor's progress notes. if not you may have to describe a little about both procedures. something probably should be said about osteoporosis as well since it is often the underlying cause of most hip fractures in the elderly. here's some links with information. - definition of fractured hip - hip fracture (includes symptoms, signs and medical management) - note the first line says that they are osteoporosis related. this site will point you in the direction of the medical treatment of hip fractures - fracture repair - hip arthroplasty (hip replacement), the surgery, preop preparation and aftercare - the low down on osteoporosis - osteoporosis tutorial - easiest is to choose the third option and pull up the text version and read the text - illustration of a hip fraction on medline plus website - what is a bone x-ray? - links to information on assistive devices

    as far as the actual nursing care plan goes, you can see an explanation of the nursing process here on this older thread about a patient with an appendicitis it includes a list of complications to look for in patients who have had general anesthetic which is something you will need to be watching out for in this patient. for other resources on writing care plans you should also review the posts on these threads if you haven't already done so:

    choosing nursing diagnoses is always based on the symptoms the patient is having. you can assume three symptoms for this patient right off the bat:
    • a wound/dressing that will need looking after
    • postoperative surgical pain
    • potential breathing problems related to being intubated
    these lead to these nursing diagnoses (in priority order):
    until you know more about the patient and her actual signs and symptoms you will find when you actually get to care for her on tuesday, what else can you plan for? your short term goals are predictions of what should happen when you apply your nursing interventions. for now, i would review the basic nursing care you need to give to a post-op surgical patient.
    • assessing and monitoring her respiratory system, the patency of her airway, checking that her lungs are clear or describing any other sounds you hear on auscultation.
    • she should be deep breathing and coughing and/or use an incentive spirometer at least every hour. sputum isn't usually forthcoming in the first postop day, but these efforts pay off in subsequent days.
    • vital signs
    • checking peripheral pulses, checking for peripheral edema, checking for numbness or tingling in the operative limb
    • assessing the range of motion in all extremities, particularly the operative limb
    • following the activity and any ambulation orders and that she is moving. if she is not getting out of bed, she should be re-positioned, not necessarily turned, at least every two hours.
    • assessing her level of consciousness
    • assess the surgical wound and any drains. note color, presence of any redness, swelling or drainage and what the sutures or staples look like. don't remove the dressing that the doctor put in place in the or. don't remove any dressing without checking with the staff first.
    • watch her intake and output and if she is nauseated or not.
    • if iv fluids are still infusing, you'll need to keep on eye on them as well as her iv site. she may be getting iv antibiotics postoperatively.
    • make sure she is voiding and has voided since surgery.
    • make sure she is getting adequate pain medication.
    pretty much all the above can be worked in as interventions for the three nursing diagnoses i gave you. i leave you and your partner to work this into something more complicated. the goal on postop day #1 is to make sure the patient is recovering from anesthesia, make sure she is comfortable, and watch for the development of any complications.
  5. by   autopsy
    Thank you so much daytonite, it was VERY VERY Helpful!! i appreciate it!