Care plan road map to be used with simple nursing PDF

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Podemos actuar mejor Care plan road map to be used with simple nursing.com’s patho bible A care plan is how you plan to care for that Pt while they are in the hospital! The admitting DX is not the priority problem. The priority problem is going to depend on your initial head to toe assessment for that day. The priority problem/s may change day to day. Understand that you will be picking your priority problems from maslow's hierarchy of needs. If the basic needs are met move to the next, if those are met move to the next level and so on. ALWAYS start with basic needs. These are Pt specific

DO NOT - Use medical diagnoses, use R/T disease process - Interventions/ rationales MUST match and support the priority problem - Forget to cite your sources and reword the nanda and rationales - Use old care plans or others care plans DO - Use multiple priority problems - Use multiple resources, reuse old citations keep them in a document - Use NANDA approved dx that are not medical DX, that correlate with your patient “Risk for “ varies by school, see instructor for details.

Patho /risk factors List the entire path of the disease process/ admitting dx for why the pt is under your care. s/sx should only be related to the patient you are writing your care plan on. Risk factors are only those that pose a risk to your PT. nothing related to your pt? You have the wrong priority problem!!!!! Formulate your nursing dx Priority problem should be based on pts needs ( see maslow's) , ask your self questions based on maslow's needs and how it relates to your pt. Examples : -02: is my patient's airway clear of objects or mucous? is my patient breathing effectively? - Safety: Does my pt feel safe? Is their home/environment safe? - Anxiety : has my pt expressed fear? Are they anxious? Are they coping? - knowledge : does my pt know why they are here? Are they able to care for themselves? Priorities examples : - Airway : ineffective airway clearance - Breathing : impaired or ineffective gas exchange - Circulation : decreased cardiac output, risk for shock , bleeding - Acute pain : - Elimination problems impaired or ineffective elimination, painful elimination R/T This will be what the problem goes back to or is related to. Example ; Ineffective airway clearance R/T thick sputum and unproductive cough. As evidenced by / manifested by You are now the lawyer! Present your case! Give all related evidence Exapmle : AEB , thick green sputum, crackles auscultated in BIL A/P L lungs, Sp02 87 on RA , PT states “ can't breathe.”

Objective data must support priority problem! Objective data is what you can see! - Lab values, ABG, vitals, uneven/labored chest expansion , SP02 rate, sputum/ color/ thickness/amount Subjective data must support the priority problem Subjective data is what you hear - What they PT or family member states - “ pt states difficulty breathing started when he mowed the grass” - Pt states “ I have sharp pain when I breath in” Goal “S.M.A.R.T” The goal is usually the priority nanda statement turned into a positive statement PT’s airway will effective and clear AEB sp02 increase of 95-100 on room air , sputum will become thin and clear with under 1ml of mucous, breathing will become even and unlabored w/ decreased pain 2/10 by 4-17-2017. - Specific - Measureable - Achievable - Relevant - Time specific Interventions - Show a clinical pathway , what's going to help you achieve the SMART goal and be relevant to your pt and the evidence you presented. This is a clinical picture of how YOU plan to get the pt better in a reasonable time . Two assessment interventions and 3 therapeutic interventions for each set 5 interventions - “NURSE WILL” auscultate breath sounds q4h / prn w/ SOB - Nurse will administer ALbuterol 2.5mg as Q4h as prescribed by MD - Nurse will encourage ITS use q1h as prescribed - Nurse will elevate HOB 45* continuously - Nurse will encourage TCDB ( turn cough deep breathe) Q1H/ PRN - Nurse will encourage fluids 2-3l a day - Nurse will educate pt …..as needed on ( whatever they need it on) Rationales Must make sense for the pt , WHY are you do what you're doing specifically for this pt and how is it going to work! Defend your thoughts! Evaluation Was the goal met/ not met/ partially met? Give actual findings AEB xyz...on “date” evaluated ....