Care Plan Rules of the Road

8/2/2019 Care Plan Rules of the Road

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Care Plan Rules of the

RoadJill Barry RN, MSN, CPNP-PC,

ARNP

Nancy ONeill RN, MSN, CNM


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Why the torture??

Remember that the ultimate purpose ofthe care plan is to guide all who areinvolved in the care of this person to

provide the appropriate treatment in orderto ensure the optimal outcome duringhis/her stay in our healthcare setting. Acaregiver unfamiliar with thepatient/resident should be able to find all

the information needed to care for thisperson in the care plan (Sox, 2010).


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Nursing Process

Assessment

Diagnosis

Planning

Implementation

Evaluation


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Assessment


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Assessment

Primary source of data.

Helps compile a list of problems

to formulate nursing diagnoses.

2 parts

Subjective

Objective


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Data

Subjective

What the patient, family member,

or caregiver says about thesituation.

Objective Information from your senses, lab

work, diagnostic testing, and chart

review.


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Data

Do not cut/paste your data.

This is not cookie cutter data.

Only include the data that is

pertinent to that nursing

diagnosis.


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Diagnosis


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Actual Diagnosis

4 parts

Label

Definition

Defining Characteristics

Related Factors


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Risk for Diagnosis

4 parts

Label

Definition

Risk Factors

Related Factors


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Diagnostic Statements

1 part

Wellness diagnosis

Readiness for enhanced hope

Syndrome nursing diagnosis

Impaired environmental interpretationsyndrome


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2 part

Risk nursing diagnosis

Risk for infection related to openabdominal wound

Possible nursing diagnosis Possible feeding self-care deficitrelated to fatigue and IV in right hand

(Carpenito, 2002, p. 11)


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3 part

Actual diagnosis

Impaired skin integrity related toprolonged immobility secondary to

fractured pelvis, aeb 2 cm sacral

lesion(Carpenito, 2002, p. 15)


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Common Errors Use of a medical diagnosis

Pneumonia instead of Ineffective airway clearance

Use of situations Pregnancy

Alteration in nutrition: Less than body requirementsr/t vomiting secondary to pregnancy aeb weight lossof 5 pounds in second trimester.

Use of diagnostic studies

Cardiac catheterization Fluid volume deficit r/t hemorrhage secondary to

traumatic cardiac cathereterization aeb baseball sizehematoma on right thigh


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Common Errors

Use of medication side effects

Alteration in comfort related to pruitissecondary to Morphine administration.

Use of treatment or equipment

NG tube or tube feeding


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Planning


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Goal

Can be positive or negative Patient will maintain/gain

Patient will not experience/will not complain of..

Must be patient centered

Patient will Must have an adequate time frame (be attainable)

Can be long-term (weeks or months) or short-term(days)

Must be realistic

Must be specific

Must be measurable Use AEB

Patient will show no signs and symptoms of infection aebtemp


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Implementation


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Interventions

Should be specific for your patient, notyour diagnosis Teaching an adult to use an incentive spirometer

Q1 while awake may be appropriate, but for achild you would state to blow bubbles Q1 whileawake.

Use nursing based, peer reviewed sources whenproviding rationale for your interventions.

You must use a nursing journal article to support

at least 1 intervention. You may use your careplan book and/or textbook

for some interventions.


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Evaluation


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Evaluation

2 parts Evaluation of each intervention

This is your data for each intervention

Intervention: Assess patients vital signs every shift Evaluation: Patients vital signs at 1400 were BP

96/43, temp 98.9, HR 120, RR 36.

Evaluation statement for each nursing diagnosis

This is your evaluation of the goal

Goal: Patient will gain a minimum of 30 grams per

day through discharge. Evaluation: Goal met. Patient gained 35 grams

11/9/10, 45 grams 11/10/10, and 40 grams 11/11/10.Patient discharged home 11/10/10.


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References

Carpenito, L. (2002). Nursing

diagnosis: Application to clinical

practice.(9th

ed.). Philadelphia:Lippincott.

Sox, H. (2010). What is a careplan?

Retrieved fromwww.careplans.com/pages/about

Documents

Care Plan Rules of the Road