i spent a great deal of time going through your care plan. for the most part it is pretty well organized, but i did make a lot of suggestions for you. a care plan is a listing of the patient's nursing problems and strategies to do something for them. everything flows from your supporting data which come from your initial assessment of the patient.
two things: (1) is she breastfeeding? there is a diagnosis for that whether the breastfeeding is going ok or if there are problems. (2) you made mention of an episiotomy. that is a wound that requires nursing attention. i gave you a diagnosis for it below and i think that should be included in the care plan. it is also a source of potential infection.
#1 nursing diagnosis
acute pain r/t uterine contractions and stretching of cervix and birth canal
external monitoring of contractions, patient states "i am hurting," noticeable facial grimace, muscle tension, increased rr, client rates pain as 9/10, diaphoresis
what about the episiotomy?
goal: client will report that pain management regimen relieves pain to satisfactory level
outcome: client will maintain
your goals and outcomes need to be reversed. outcomes refer to the overall outcome of the diagnosis and usually go back to the related factors. goals have to do with how your nursing interventions impact on the symptoms (your supporting data).
interventions: 1. assess pain level every hour and prn 2. administer stadol iv every 4 hrs and prn3. assist with epidural
how is assisting with her epidural going to decrease her pain?
4. provide nonpharmacologic techniques
like what? this is a very vague intervention. i'll list some for you below.
5. encourage client to try different positions 6. teach simple breathing and relaxation techniques 7. limit visitors as she desires
limiting visitors doesn't belong here.
8. keep informed about the progress of labor and baby's condition
how is this going to decrease her pain? this sounds more like it needs to be an intervention with your diagnosis of anxiety.
9. prevent pain when possible during procedures - pain during procedures is not among your supporting data (symptoms), so why would you have a nursing intervention for it? makes no sense.
one of your interventions should at least be mentioning the pain scale of 0 to 10 that is being used to assess the pain since you mention it as an outcome and have included it as supporting data.
what are you doing for the diaphoresis?
#2 nursing diagnosis
fatigue r/t childbirth
supporting data ??????? help?????
how can you even diagnose that the patient is fatigued without her having any symptoms of it? your supporting data would be the symptoms of the fatigue. look at the defining characteristics of fatigue in a nursing diagnosis reference (i've given you weblinks where you can find this information below).
goal: patient will verbalize increased energy and improved well-being
outcome: patient will verbalize environment is suitable for satisfactory rest during my shift
your goals and outcome need to be reversed.
interventions:. assess level of fatigue prn 2. allow client to express what best helps her relax
3. limit visitors as she requests 4. prepare the environment to promote rest 5. administer pain medication to relieve pain and promote rest
this intervention belongs with acute pain.
6. limit the number of times she is interrupted try to administer medication, check vs, or or other actions in one room visit
do room visits cause her fatigue or anxiety? hmm. if they cause anxiety this should be part of your supporting data for anxiety and belongs with that diagnosis.
7.teach methods to help relax
#3 nursing diagnosis
anxiety r/t fear of unknown and situational crisis
supporting data: facial tension, increased perspiration, increased pulse ?????? this doesn't sound right?????
yet they are. read up on anxiety. they are physiologic responses. all are listed as defining characteristics of anxiety in a nursing diagnosis reference.
goal: patient will have vital signs that reflect baseline and will verbalize decreased anxiety
outcome: patient will have a relaxed facial expression and body posture between contractions
your outcome should reflect the related factor. goals should be predictions of what will happen when your interventions for the symptoms (facial tension, increased perspiration, increased pulse) are performed as you planned.
interventions: 1. determine the couple's plans for birth and work with them as much as possible
this makes no sense being here. you have no supporting data that their plans for birth have or are the cause of any anxiety.
2. explain all activities, procedures and issues that involve the client 3. stay with client as much as possible during labor
!!!!!!!!!!need more interventions!!!!!!!!!!!!!!
the problem with your interventions is that they do not target the symptoms of the anxiety (your supporting data, or symptoms). just like doctors, we also treat the patient's symptoms. in this case, you are saying her symptoms of the anxiety are facial tension, increased perspiration, increased pulse. your interventions need to be what you are going to do about them.
the definition of anxiety, the nursing diagnosis, is vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. it is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat (page 242, nanda international nursing diagnoses: definitions and classifications 2009-2011).
what will you do to allay those feelings of fear and dread? better still. . .did they verbalize them at all? if so, they are supporting data (symptoms) that you need to include above.
#4 nursing diagnosis
risk for infection r/t multiple vaginal exams and tissue trauma
supporting data!!!!!!!!!need supporting data!!!!!!!!!!
there is no supporting data because this is not an actual problem that exists yet. it is a potential problem. there are only risks that it could happen. the risks are that she has had xx vaginal exams and tissue trauma from xx. list it out. include that episiotomy.
goal: patient will remain free from infection
outcome: patient will free from signs of infection as evidenced by normal vs during my shift
your goal and outcome need to be reversed.
interventions: assess and report signs of infection such as swelling, discharge, increased body temp and warmth 2. follow standard precautions
what are standard precautions and why are they important to the prevention of infection?
3. use sterile technique when inserting foley 4. use appropriate hand hygiene
what is "appropriate" hand hygiene? you need to be more scientific. spell it out exactly.
5. teach patient proper perineum care 6. teach patient the symptoms of infection and when to report to physician 7. teach patient proper episiotomy care
this patient has an episiotomy? that's another nursing problem and diagnosis impaired tissue integrity.
8. monitor vs
again, outcome should be that the patient will be free of infection. goals will reflect predictions of what will happen when your interventions for the potential symptoms do not occur or your interventions are performed as you planned. with "risk for" diagnoses nursing interventions are restricted to the following:
strategies to prevent the problem from happening in the first place
monitoring for the specific signs and symptoms of this problem
reporting any symptoms that do occur to the doctor or other concerned professional
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interventions for pain:
assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
assess and document where the pain is located and what, if anything, makes it worse or better
observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
give pain medication as ordered
provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
reposition the patient
give a back massage
use short, simple relaxation exercises to distract the patient's attention
dim the lights in the room and keep noise down
play soft, soothing music
have the patient perform slow deep breathing and concentrate on feeling weightless with each breath
reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting
teach the patient about prescriptions they will be going home with including the dosage, how they should be taken and any side effects
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symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
- - - - - - - - - - - - - -
these are nursing diagnosis pages that refer to the nursing diagnoses you are using for this patient. on them you will find the defining characteristics (symptoms) of each of these nursing problems.
http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=40 - acute pain
http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=19 - fatigue
http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=03 - anxiety
[*]risk for infection
risk for infection
http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=32 - risk for infection