Proofing 1st Nursing Care Plan

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Hi, this is my first post and I'm not sure if anyone would be willing to proof this care plan for me or not, but hopefully someone will give me their opinion. We have to complete 1 nursing diagnosis for a care plan (our first) so if someone would read over this and leave comments, I'd appreciate it.

Thanks !!

Acute pain r/t vascular inflammation secondary to DVT.

AEB: 1) Pain level of 8 on 0-10 scale.

2) Edema in right leg.

3) Facial grimacing.

4) Pt reports "uncomfortable and pressure on lower legs when in bed."

Pt Goals:

1) The pt will report relief of pain to a level of 5-6 on pain scale of 0-10 by 1/23/09 0900.

2) The pt's right leg will have a reduction in edema by 1/23/09 0900.

3) The pt will report relief of pressure on lower leg when in bed by 1/23/09 0900.

4) The pt will exhibit less facial grimacing by 1/23/09 0900.

Plan:

1) Administer Dilaudid 1 mg q4h PRN 1/23/09 0900.

2) Assist reduction of edema by elevating lower legs on pillows below the knee PRN 1/23/09 0900.

3) Provide comfort by elevating lower legs on pillows below the knee PRN 1/23/09 0900.

4) Assess pain in patient by using self report on pain sacle 0-10 q4h 1/23/09 0900.

5) Provide emotional support by talking with patient PRN 1/23/09 0900.

6) Assess edema in right leg by comparing it with baseline circumference measurements q8h 1/23/09 0900.

Rationale:

1) Dilaudid blocks pain receptors inhibiting the transmission of pain, which provides pain relief.

2) Elevating the legs removes pressure, promotes the return of blood through leg veins, which reduces edema.

3)Elevating the legs removes pressure, promotes the return of blood through leg veins, which provides physical comfort to the patient.

4) Assessing the patient's pain level indicates if relief measures are working and provides valid and reliable measures of pain intensity.

5) Providing emotional support assists in relieving the patient's fear, anxiety, and provides distraction, assisting the patient in coping with pain.

6) Assessing edema in the right leg by measuring circumference and comparing to baseline measurements provides a reliable measure of edema reduction.

Evaluation:

(I think this part is very easy, so don't need it proofed)

Thanks a Bunch for any advice !!!

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Specializes in LTC, Cardiac Step-Down.

Heck of a lot better than my first Care Plan LOL

The only thing I can see a problem with is your intervention to administer Dilaudid. Since that's something only a doctor can order, my instructors wouldn't count that as a NURSING intervention.

Otherwise, you did very well having everything go back to the diagnosis of acute pain.

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well, it's a good care plan since you made it specific, measurable, attainable, realistic and time-framed. i think the only thing that you should indicate is that the first intervention is a dependent nursing intervention. there is no problem in including other interventions that is being actually performed by other professions as long as you include those interventions at the dependent nursing interventions. even though it is the action of others, we too nurses has a role in that action. like giving that medication, we should know when to give that kind of medication and why is that med is given to that patient. it is also our responsibility to watch out for some adverse effect of the drug. hope this one will help. good luck for your future care plans.:yeah:

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Specializes in Adult Med/Surg.

stalisha - very brave of you to post your careplan!!! I admire your resoursefulness! A couple of points: :typing edema is not a manifestation of pain. (your AEB #2). Your goal: "The pt will report relief of pain to a level of 5-6 on pain scale of 0-10 by 1/23/09 0900" is definitely measurable, but I'm wondering where you got the 5-6? Is that YOUR idea of what the client's pain should be or is it "the patients stated pain goal of 5-6." Also, by 0900 seems rather arbitrary. When it comes to pain relief, your intervention should reflect resolution (or at least reassessment) within 30 minutes of intervention. You have your intervention of administering Dilaudid at 0900 and the patient goal of pain relief is 0900. That's some pretty wicked dilaudid!!! You plan of "Provide comfort by elevating lower legs on pillows below the knee" needs to be a wee bit more specific - if you put pillows just under the calf, you could be increasing pressure on the DVT site, potentially worsening the condition. Pillows should be wedged from the thigh to the ankle to distribute the pressure evenly.

On your evaluations - you say you don't want those proofed, but you might consider writing your evaluation as you would for legal documentation. Don't just say "goal met;" rather describe how the goal was met. If it was partially met, describe what parts were met and whether or not you, the nurse, think that the remaining goals are still reasonable. If the goal is not met, describe the barriers. Does the goal need reworking... etc.

Overall, you've got a pretty good careplan!!! Keep up the good work! :wink2:

Oh, PepperAnn - administration of a PRN order IS an appropriate nursing intervention.

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Thanks for all the advice. As to the time frames, we were told to make the goals attainable by 24 hours time. The Dilaudid would be administered q4h PRN for 24 hours, and it would be evaluated 30 minutes after administering. And the 5-6 was a goal set with the patient. We were also told that we could use 1 dependent nursing intervention and i'm counting the Dilaudid as that one since I would need a physician's order for it.

Thanks for the advice on clarifying the legs on pillows, I am going to do that now.

I really appreciate the feedback as this is my very first care plan !!!

Thanks Tons !!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

acute pain r/t vascular inflammation secondary to dvt.

aeb: 1) pain level of 8 on 0-10 scale.

2) edema in right leg. - edema is a related factor and is actually a symptom of inflammation so it cannot be a symptom of pain.

3) facial grimacing.

4) pt reports "uncomfortable and pressure on lower legs when in bed."

pt goals:

1) the pt will report relief of pain to a level of 5-6 on pain scale of 0-10 by 1/23/09 0900.

2) the pt's right leg will have a reduction in edema by 1/23/09 0900. - this is not specific enough based on the interventions you have; you are doing calf measurements and leg elevations. in 24 hours you may or may not see a decrease in the calf measurement. calf measurements are measurable. this, however, depends on the patient's reaction to the antibiotics and/or the dissolution of the thrombus which will take more than 24 hours.

3) the pt will report relief of pressure on lower leg when in bed by 1/23/09 0900. - this is a patient perception and pretty much dependent on whether or not the edema is resolving within your 24 hour time period.

4) the pt will exhibit less facial grimacing by 1/23/09 0900. - i would re-word this. facial grimacing is something we observe. "less facial grimacing will be observed. . ." (just my opinion.)

plan:

1) administer dilaudid 1 mg q4h prn 1/23/09 0900. - you need to add "as ordered by the physician" since this is not an independent nursing action. i would also evaluate the effectiveness of the dilaudid in reducing the pain.

2) assist reduction of edema by elevating lower legs on pillows below the knee prn 1/23/09 0900. - "assist reduction of edema" is a rationale and that goes in your rationale section.

just state "elevate lower legs on pillows."

3) provide comfort by elevating lower legs on pillows below the knee prn 1/23/09 0900. - "propvide comfort by" is a reason for why you are doing this and does that really need to be explained? this is the same intervention as #2. just state "elevate lower legs on pillows."

4) assess pain in patient by using self report on pain scale 0-10 q4h 1/23/09 0900. - you have nothing else about assessing where the pain is, what other symptoms to assess for, how long the pain lasts or what brings it on. this should be your first listed intervention for this diagnosis.

5) provide emotional support by talking with patient prn 1/23/09 0900.

6) assess edema in right leg by comparing it with baseline circumference measurements q8h 1/23/09 0900. - you measure both legs to provide comparisons. "measure the circumference of both lower legs at their widest point daily and record." also, this is out of sequence. move it up around with the leg elevation interventions.

rationale:

1) dilaudid blocks pain receptors inhibiting the transmission of pain, which provides pain relief.

2) elevating the legs removes pressure, promotes the return of blood through leg veins, which reduces edema. - elevating the legs does not remove pressure. the pressure in the legs is created by the swelling of the inflammatory process.

3)elevating the legs removes pressure, promotes the return of blood through leg veins, which provides physical comfort to the patient.

4) assessing the patient's pain level indicates if relief measures are working and provides valid and reliable measures of pain intensity.

5) providing emotional support assists in relieving the patient's fear, anxiety, and provides distraction, assisting the patient in coping with pain.

6) assessing edema in the right leg by measuring circumference and comparing to baseline measurements provides a reliable measure of edema reduction.

there are a lot more interventions that can be done for pain. repositioning. many different distraction techniques involving relaxation exercises (especially if the patient is on bedrest), giving back massages, dimming the lights and quieting the environment, having the patient use visualization or guided imagery, listening to music, deep breathing to help with relaxation. explain how drugs and the other pain management techniques can work together to relieve the pain. pain assessment always involves not only intensity (the 0 to 10 scale) but duration, location and reaction.

assessment of pain:

  • where is the pain located?
  • how long does it last?
  • how often does it occur?
  • what words does the patient use to describe the pain?
  • what triggers the pain?
  • what relieves the pain?
  • what makes the pain worse?
  • what is the level of pain on a scale of 0 to 10
  • what is the patient's behavior to the pain: changes in body position, moaning, sighing, facial grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility

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Thank you for the advice. I realize there are a lot more interventions, etc that can be done for this, but this is our very first care plan and we were told to come up with one nursing dx, 4 or 5 goals, 4 or 5 interventions and rationales, etc

I really appreciate the feedback and I have made some changes based on your post.

Greatly appreciated !

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i have no problems critiquing someone's care plan. i take a lot of time going though them and i try very hard not to sound too harsh. some misunderstand my bluntness as being mean. you don't ever need to defend your work because i never know what your instructions for the assignment were. what i do know is what a dvt is, how it happens, how the docs usually treat them and what we did for patients that were hospitalized with them. you were too focused on the edema. i understand why. you were going after the etiology of the pain. however, the edema is due to the inflammatory response and that isn't going to be resolved in 24 hours. that will be resolved as the dvt heals and nursing interventions for pain aren't going to do that. your problem is pain. focus more on treating the pain. group your interventions together in a logical way. they are kind of scattered around as you have them listed now. also, i was thinking after i hit the "submit" button yesterday that you have no teaching interventions. there are 4 types of nursing interventions:

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
  • care/perform/provide/assist (performing actual patient care)
  • teach/educate/instruct/supervise (educating patient or caregiver)
  • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

it would be nice to come up with at least one of each type. you did well for your first care plan. very detailed. just needs fine tuning.

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Day tonight I know that you said you had to leave nursing for personal/health reasons. Would those same reasons prevent you from becoming a instructor? I know you've been asked this a thousand times but could you?

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Specializes in med/surg, telemetry, IV therapy, mgmt.
Day tonight I know that you said you had to leave nursing for personal/health reasons. Would those same reasons prevent you from becoming a instructor? I know you've been asked this a thousand times but could you?

Unfortunately, they would.

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Specializes in Adult Med/Surg.

Good luck on your careplan - let us know how you did!!!!

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