PLEASE HELP<< CARE PLANS

ShelleyERgirl, LPN · Mar 26, 2004

Hey Kem,

I hope this helps, I don't start my OB rotation until next week, but I do have my book, and I found an example of a care plan for your nursing dx for ineffective airway clearance R/T excessive mucus production.... My text book is " Maternity Nursing" sixth edition by Lowdermilk and Perry, page 505. Good luck to you!

KolkataMomRN · Mar 26, 2004

Risk For Fluid Volume Deficit R/T poor suck

Goal: Pt. will not demonstrate signs and symptoms of dehydration

Interventions: Monitor weight, body temperature, moisture in oral cavity

and urine volume and concentration

Offer appealing forms of fluids

Risk For Ineffective Airway Clearance R/T increased mucus production

Goal: Pt. will not experience aspiration

Interventions: Position to prevent aspiration

Suction secretions from airway as needed

Provide humidified atmosphere

Rrisk For Altered Thermoregulation r/t large body surface area and cool environment

Goal: The infant will have a temp. between 97.5 F and 98.6 F

Interventions: Warp in two blankets

Put on head cap

Limit time in contact with wet clothing or blankets

Warm all articles for care

Risk For Injury (misidentification) r/t helpless infant

Goal: Pt will not be misidentified.

Interventions: Frequent checks to ensure identification is intact

Ensure identification is intact on bed

Hope these help.......

Tammy

Lys · Mar 27, 2004

Kem,

I had *major* troubles with my ND's too...but thankfully have found the light *lol* This article may help you wrap your head around differences between interventions and goals (which is what I had the most difficulty with).

Tribulski, Jean A. (1988). Nursing diagnosis: waste of time or valued tool? Registered Nurse Dec 1988, pp 30-34.

In a nutshell just in case you cant' get the article anywhere:

Example: Fluid volume excess related to excess sodium intake.

Condition (nursing diagnosis) = patient goals.

i.e. fluid volume excess = goals, weight loss, no pulmonary edema, choose low sodium items from menu.

Etiology (related to factors) = interventions

i.e. excess sodium intake = interventions, weight QAM, monitor I & O, assess breath sounds...etc.

Best of luck with the ones that your instructor gave you, KolkataMom hit the nail on the head for you!!

KolkataMomRN · Mar 27, 2004

KolkataMom hit the nail on the head for you!!

Thanks Lys!! I actually have had a lot of trouble with nursing care plans in school. I was looking at them the wrong way and making them way too complicated.

It finally hit me one day, that the goal it is the outcome that the PATIENT will do. While the interventions are something the NURSE will do to help the patient reach the goal. I know, I know they told me this in class, but for some reason it just was not clicking :rolleyes:

So with airway clearance, the ultmate goal is for the pt. to not aspirate. So what can I do, while with the pt., to help him/her not do this (interventions)............... I think some instructors make them sound way to complicated. Kem, forget fancy wording, keep it simple, and you will prgress with them.

bangkay · Mar 27, 2004

quick nemonics

NCP:

Assessment Nsg DX Goals Objective Nsg Implementation Evaluation

Cues Problem How,Able? Doing,Action Did it work?

Subjective Etiology SMART Documenting Goalmet

Objective ManifestationShort/long term

SMART- Subjective, Measurable, Attainable, Realistic, Time bounded

Hope this will help

kem7 · Mar 27, 2004

thank you so vey much this was very helpful :) cit R/T poor suck