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For your Paper: Diagnosis Signs & Symptoms Your patients Signs and Symptoms Pathology Lab values related to diagnose and then what were your patients lab values (did they correlate?) Medications AND why these specific meds? Care Plan
Below are a couple examples of Nursing Care Plans. You may want to check the sites I have provided you as well. No cutting and pasting. Work must be yours. Remember when prioritizing client needs: The ABC's are 1st and, don’t forget Maslow's Hierarchy of Human Needs. Physiological needs always come first: Breathing, Bleeding, Water, Food, Sleep, Excretion, Think of what is necessary for survival. Everything else comes after that. The development of a nursing care plan steps developed from the nursing process which includes: 1. Assessment - collection of patient data 2. Determining the Nursing Diagnosis with identification of nursing diagnoses, goals and outcomes 3. Planning – Actually putting together and writing the care plan (include interventions) 4. Implementation - putting the Care plan into action 5. Evaluation – How will you evaluate it and ensure it is periodically updated Try the following websites: http://www1.us.elsevierhealth.com/Ev...uctor/A-B.html http://www.rncentral.com/nursing-library/careplans/bec http://www.childbirths.com/euniversity/sample%20care%20plan.htm The following links to case scenarios show you, in steps, how to develop a nursing care plan using NANDA languages. They are learning activities for the nurses working for a facility owned by the University of Michigan. In these scenarios the nurses are directed to choose nursing diagnoses, NOC outcomes and NIC interventions (this is all terminology that NANDA uses). Unfortunately, no answers are provided. However, you can see how the process is supposed to flow from one step to the next and some of the critical thinking that goes into the making of the care plan. http://www.med.umich.edu/nursing/snl/cs2.pdf - this is a adult surgical care planning case study activity http://www.med.umich.edu/nursing/snl/cs3.pdf - this is an adult ICU care planning case study activity http://www.med.umich.edu/nursing/snl/cs4.pdf - this is a pediatric care planning case study activity http://www.med.umich.edu/nursing/snl/cs5.pdf - this is a pediatric ICU care planning case study activity http://www.med.umich.edu/nursing/snl/cs6.pdf - this is a prenatal care planning case study activity http://www.med.umich.edu/nursing/snl/cs7.pdf - this is a psychiatric care planning case study activity http://www.med.umich.edu/nursing/snl/cs8.pdf - this is an ambulatory patient care planning case study activity
Example Nursing Diagnosis and Careplan for N205 Mini careplans Potential for Injury (Apsiration)
Assessment Data Related to Nursing Diagnosis
What Objective and Subjective Data lead you to this one diagnosis. Objective: CVA with Left Sided Paralysis Diminished Gag Reflex Difficulty Swallowing Liquids
Evaluate based on the patients progress towards each of the outcome Criteria 1. Patient did not have problems with choking during my shift. Patient color was pink. Patient lung sounds remained clear. You may or may not have lab/X-ray data to report, depending on the day and what tests have been ordered.
Potential for Injury (Aspiration) Goal (Should be broad statements which Interventions should be things that related to dimminshed gag reflex solve the Problem part of the Nursing you do (either independently or and impaired swallowing ability Diagnosis Statement. ) dependently) to assist the patient in reaching the goal. They should be focused on addressing the cause of Patient will not have injury related to the problem (the related to part of aspiration (10/20/95 2-10pm) the nursing diagnosis statement) Outcome Criteria Specific and observable things which allow an observer to determine if the patient met the goal Place patient on side or with HOB to avoid aspiration of mucous. Feed patient liquids which have been thickened, as thin liquids are more likely to cause aspiration. Monitor lung sounds for signs of aspiration Monitor Lab and X-ray data for signs of aspiration.
2. 3. 4.
Subjective (from patient or family) " Mom chokes every time she eats". 3.
Patient will have no choking episodes while eating. Patient color will remain cyanotic Patient lung sounds will remain clear Patient CXR will show no signs of aspiration
Goal Met, Continue Plan. ALSO INCLUDE Was this an appropriate Nursing Dx for THIS PATIENT? It may turn out that after you care for the patient, you discover a higher priority nursing diagnosis.
Sample Nursing Careplan for N205 : Fluid Volume Excess
Assessment Data Nursing Diagnosis Goal: Patient will not have fluid volume excess Interventions
1. 2. 3. 4. 5. 6. 7.
Clients weight was stable at 145 lbs. Client stated she could breathe better Lungs had decreased crackles Vital signs were T 98.6 P 87 R 24 B/P 134/86 Na was 135 Hct was 36 Urine was clear yellow with output over 30 cc/hr Intake was 350 cc this shift with output of 475 = Negative fluid balance of 125 cc this shift. There was no skin breakdown
(List the things your patient Fluid volume excess RT water retention Outcome Criteria: Restrict fluids to 350 cc per shift. has which make you suspect secondary to decreased renal perfusion SR: Excessive fluids will worsen client's he/she is overhydrated) and cardiac output 1. Client's weight will be condition. (Sparks, 110) Objective: WNL for Ideal Body Weight gain in past month Weight (give numbers). Weigh client at same time each day, using same Edema scale. SR: Provides baseline and continuing 2. Client will verbalize Tight, shinny skin database for monitoring changes and evaluating ability to breathe Crackles in lungs interventions. comfortably. Decreased urine output (Brunner, 1039) 3. Lungs will be clear Na level 134 4. Vital Signs will Be WNL Hct level below 35 Administer diuretics (Lasix) as prescribed. SR: 5. Relevant lab values To increase excretion of water. (Ulrich, 508) (Sodium, Hct) will be Subjective: WNL ( Na 135-145) etc. Help client into a position that aids breathing, such as Fowler's or Semi-Fowler's. "My feet and legs are so 6. Urine will be clear SR: To increase chest expansion and improve swollen" yellow with output ventilation. (Sparks, 110) "I just can't breath if I'm flat >30cc/hr in bed" 7. Intake will not be greater Encourage client to cough and deep breathe q2h. than output SR: To prevent pulmonary complications. (Sparks, 110) 8. No evidence of skin breakdown.
Asculatate Lung Sounds q 4 hours. Monitor Pulse Ox Q 4 hours, Monitor CXR results, as performed. SR: To look for pulmonary vascular congestion, 9. pleural peffusion, or pleural edema. (Ulrich, 508) Assess vital signs q4h. Assess lab values q shift. Monitor extremities for venous return (check pulses and capillary refill) q shift. SR: Decrease in venous blood flow results in an increase in venous pressure, a rise in capillary hydrostatic pressure, a net filtration of fluid out of the capillaries, and thus edema. (Brunner,625) Administer vasodilators, as ordered. SR: To improve renal blood flow. (Reduced renal
perfusion stimulates the renin-angiotensinaldosterone mechanism) (Ulrich, 508) Encourage client to restrict Na intake. SR: Restriction of NA intake reduces the amount of Na that passes through the kidney and is reabsorbed. This results in decreased retention of water. (Ulrich, 37) Test urine specific gravity q8h. SR: High specific gravity indicates fluid retention. Fluid overload may alter electrolyte values. (Sparks, 110) Examine skin q8h for signs of bruising or other discoloration. SR: Edema may cause decreased tissue perfusion with skin changes. (Sparks, 108) Skin care q4h. (Cleanse wound with saline, dry, apply polysporin and dry gauze dressing.) SR: To prevent further skin breakdown. (Sparks, 108) Reposition client q2h.
References Brunner, L.S. & Suddarth, D.S. (1988). Medical-surgical nursing. Philadelphia: Lippincott. Sparks, S.M. (1993). Nursing diagnosis reference manual (2nd ed.). Springhouse, PA: Springhouse Corporation. Ulrich, S.P., Canale, S.W., & Wendell, S.A. (1994). Medical- surgical nursing care planning guides (3rd ed.). Philadelphia: Saunders.
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