TheNursingStudentsPracticalGuide toWritingCarePlans

ByLuanneBegin

PREFACE
Congratulationsforchoosingnursingasyourcareer!Thenursingprogramhere atBristolCommunityCollegewillprovideyouwiththeacademicknowledge andclinicalskillsyouneedtopasstheNCLEX,obtainyourlicense,andbegin workingasaregisterednurse.Youwillfacemanychallengesoverthenexttwo yearswhichwillrequireyoutoworkdiligentlyandconscientiouslyinorderto meettheprogramobjectivesandachieveyourgoals.Youwillbeexpectedto consistentlystrivefor,reach,andthenexceedyourpersonalbestasyouprepare toentertheprofessionofnursing.TrustmewhenItellyouthatitcanbedone! AsarecentgraduateofthenursingprogramIunderstand,fromastudentspoint ofview,theuniquestrugglesyouarefacing.Icanrememberbeingexactly whereyouare...intimidatedandoverwhelmedbythedauntingtaskofwriting theperfectcareplan;or,ifnotperfect,atleastgoodenoughtoearnthatcoveted andallimportantsatisfactoryfrommyclinicalinstructor.IoftenwishedIhad anexample,ormodel,thatIcouldfollowwhichwouldassistmeinnavigating mywaythroughthewritingrequirementsofthiscurriculum.Myfellow studentsandIoftenremarkedonhowmucheasieritwouldbetowriteacare planifonlywehadoneinfrontofustolookat!AsalongtimetutoratBristol CommunityCollege,Ihavealwaysbeenpassionateabouthelpingother students,andsoastheendofnursingschoolapproached,Idecidedtocreatethis manualinthehopethatitwouldgiveincomingstudentsthekindofmodelmy classmatesandIalwayswishedwedhad. Thismanualhasbeendesignedtoassistyouinmeetingthewritingrequirements ofthenursingprogram.Itisimportanttounderstandthattheclinical componentofthiscurriculumisnotlimitedtosimplymasteringtechnicalskills andprovidingdirectpatientcare;itrequiresyoutocriticallythink,andthen writeabout,allaspectsofthatcare.Beforeyouevermeetyourpatient,youwill beaskedtoconductresearch,collectdata,andpresent,inwriting,a comprehensiveplandetailingyourunderstandingofthatpatient,includinghis orhermedical,physical,emotional,andpsychosocialneeds,andhowyouplan tomeetthoseneeds. i

Attheendofeachweek,youwillreflectonyourexperienceintheclinicalarea andthenwriteaselfevaluationdocumentingyourthoughtsandfeelingsabout yourperformance.Asatutor,Iunderstandthatmanystudentsareintimidated by,orsimplyuneasyabout,theprospectofwriting.Worse,Ivemetquiteafew whoclaimtohateit!Ifyoubelieveyourselftobeinoneofthesecategories,then thismanualisforyou.Ithasbeendesignedtoeliminateanyreservationsyou mayhaveaboutyourabilitytowritesuccessfully,andwithconfidence,by showingyouexactlywhatyoucanexpectregardingcareplansandself evaluations.Ihopeyouwillfindthisapracticalandvaluablelearningtoolas youstriveforexcellenceintheclinicalarea. Asyoumakeyourwaythroughnursingschool,strugglingandsacrificing, pleasetakethetimetoremindyourself,often,thatyouhavebeenselectedfor oneofthefinestnursingeducationprogramsinthisregionandthatyoucan,and will,meeteachchallengesuccessfully,andberewardedbeyondmeasurefor yourefforts. LuanneBegin StudentNurse,Classof2007 BristolCommunityCollege ii

ACKNOWLEDGMENTS
Iwouldliketothankthefollowingpeople: Dr.CynthiaHahn,formakingmelovechemistryandrecommendingmetothe TutoringandAcademicSupportCentertherebyintroducingmetothe wonderfulworldofbeingatutor. Dr.RonaldWeisberger,whoseinfectiouspassionforpeertutoringinspiredmeto helpothers,bothinsideandoutsidetheTASC. ProfessorDianaDonnieMcGee,forencouragingmetobegintutoringinthe WritingLabandinsistingthatIentertheCommonwealthHonorsProgramI neverwouldhaveconsideredsuchathingwithoutherinfluence. NicoleDeLano,forgenerouslysharingherFundamentalscareplans,beinga friend,alwayshavingasmile,andfindingthetimetoinspireothers. LynneCaron,forthewritingsamplessheprovidedtotheWritingLab;forthe friendship,support,andencouragementthroughoutthese2years;foralways pickingupthephonewhenIspeeddialedhernumber;and,ofcourse,forallthe pancakesandcrazypneumonics.InotonlyearnedaNursingdegree,Igaineda lifelongfriend. Dr.HowardTinberg,forhistime,patience,anddedicationtothisstudent,and towriterseverywhere;forhisspecialwayofhelpingawriterseethevalueof theirwork;forhispraise,whichisalwaysgenerous,andhiscorrections,which arealwaysgentle.Thisprojectwouldnothavebeenpossiblewithouthis wisdom,insight,andguidance. Finally,Ineedtothankmyfamily,forlivinginamessyhouseandeatingalotof takeoutwhileIspenthourswiththecomputer.

TABLEOFCONTENTS
SectionOne:TheNursingProcess.................................1 Assessment....................................................1 Diagnosis......................................................1 Planning.......................................................2 Implementation.................................................3 Evaluation.....................................................3 SectionTwo:WritingaCarePlan..................................5 GettingStarted..................................................5 DataCollectionandOrganization.................................5 ConductingResearch............................................7 EvaluatingYourPriorities.......................................10 Revisions......................................................10 SectionThree:SampleCarePlans.................................12 Fundamentals:NUR11..........................................12 MedSurg:NUR51&52.........................................19 WhySuchLongCarePlans?.....................................39 SectionFour:SelfEvaluations....................................41 NUR11&12...................................................43 NUR51&52...................................................48 Afterword......................................................51 References......................................................52

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Section One: The Nursing Process

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Potter&Perry(2005)describesthenursingprocessasasystemtoorganizeand delivernursingcare(p.279).Asyoumayalreadyknow,thenursingprocess consistsoffivesteps:assessment,diagnosis,planning,implementation,and evaluation.Whileyouhavestudiedeachoftheseaspectsofthenursingprocess indepthduringyourcorecurriculum,Ithoughtitmightbehelpfultoprovidea briefoverviewofhoweachofthesestepsappliestocareplanning.

Assessment
Assessmentisthedeliberateandsystematiccollectionofdata(Potter&Perry, 2005).Thisistheveryfirststepinwritingacareplan.Indeed,itwouldbe almostimpossibletocreateamapofcareforapatientaboutwhomyouhaveno information.Ontheeveningbeforeclinical,youwillwriteyourcareplanbased entirelyoninformationyouhavegatheredfromthepatientswrittenrecords. Althoughyouhavenotyetseen,touched,smelled,orlistenedtoyourpatient, thisresearchofthepatientschartisassessment.Itallowsyoutounderstandthe patientshistory,reasonforadmissiontothehospital,currentmedications, laboratoryvalues,andcurrenthealthstatus.Youcannotproceedtothenextstep incareplanningwithoutit.Pleasetakemyadviceandconductathorough examinationofyourpatientsmedicalrecord;youdonotwanttobeathome writingacareplanonlytorealizethatyouaremissingacriticalpieceof information.

Diagnosis
Nursingdiagnosesareclinicaljudgmentsaboutactualorpotentialproblemsa patientmaybefacing.Basedonyourassessment,youwillidentifythenursing diagnosesmostappropriateforyourpatient.TheNorthAmericanNursing DiagnosesAssociation(NANDA)istheorganizationthatdefinesandclassifies nursingdiagnoses.Itisrequiredthatalldiagnosesincludedinyourcareplanbe NANDAapproved.ThisisimportantbecauseNANDAprovidesacommon languagethatallnursesuseandunderstand.Youhavepurchasedarequired textthatprovidesyouwithacomprehensivelistofNANDAapproved 1

diagnoses.Earlyoninyourcareerasanursingstudent,youareexpectedtouse onlythattextasaresource.Later,youmaybeallowedtouseseveraldifferent textsonnursingdiagnosesand/orcareplanning,dependingonyourinstructors preferences,aslongasallyourdiagnosesremainNANDAapproved.Ifyour instructordoesnotobject,youwilldefinitelywanttoinvestintwoorthree nursingdiagnoses/careplanningbooks. Inyourfirstyearyouwillbeginbyidentifyingonediagnosis,thenprogressto identifyingthree,andthenfive.Inyoursecondyearyouwillidentifyfifteen. Youwillalwaysbeginwiththenursingdiagnosiswiththehighestpriorityfor thepatient,andproceedtolisttherestinorderofdecreasingpriority.Todothis, usetheBasicHumanNeedslist(appendixA).Generally,anactualdiagnosis takespriorityoverariskfordiagnosis.Forexample,ImpairedSkinIntegrity(an actualproblem)wouldbeahigherprioritythanRiskforInfection(apotential problem).However,therecanbeexceptions,andmostofthese,thankfully,can bediscernedwithcommonsense.RiskforInjurywouldnaturallytake precedenceoverActivityIntolerance. Thewritingprocessisimportantwhenitcomestodiagnosis.Youmayfindit helpfultofirstthinkaboutandthenwritedownonapieceofscrappaper, withoutregardtowhatismostimportant,anyandallproblemsyoubelievethe patientmayhavebasedonyourassessment.Fromthere,youcancriticallythink aboutandbegintorankyourdiagnosesaccordingtopriority,beforecommitting toactuallywritingtheminyourcareplan.

Planning
Theplanningphaseofthenursingprocessiswhenyouwilldecidewhichcare measuresareappropriateforyourpatient.Eachnursingdiagnosislistedinyour textwillhaveacorrespondinglistofinterventionsandrationales.Planningcare involvescarefullyreadingthougheachlistedinterventionandaskingyourselfif thatinterventioncanorshouldbecarriedoutwithyourpatient.Forexample,an interventionlistedunderImpairedGasExchangereadsasfollows:Ifthepatient isobeseorhasascites,considerpositioninginreverseTrendelenbergsposition at45degreesforshortperiodsastolerated(Ackley&Ladwig,2006,p.439). Now,ifyourpatientisnotobeseanddoesnothaveascites,thisinterventionis notindicatedandshouldnotbeincludedinyourplanofcare.Toreiterate, includeonlythosecaremeasureswhicharerelevanttoyourpatient. Itisveryimportantthatyoulearn,earlyon,howtomakeyourinterventions specifictoyourpatient.TrustmewhenItellyouthatyouwilllikelysave 2

yourselfalotoftime,andpossiblyavoidhavingyourcareplanreturnedtoyou forrevisions,ifyouareconscientiousaboutdoingthis.Asanillustration, supposeyouhaveadiagnosisofAcutePainandoneofthelistedinterventionsis administeranalgesics,asneeded.Whatyouwillneedtodoislookatyour patientsavailablemedicationsforpainreliefandwritetheinterventionas follows:administerDilaudid,2mg,IVq4hours@0800and1200.Noticethat themedication,dose,route,andscheduleislistedandthatthetimesarespecific totheshiftwhenyouwillbecaringforthepatient.Also,becognizantoftheuse ofpronounsinyourinterventions.Useheorshewhereappropriate.Thislets yourinstructorknowthatyouaretailoringyourcaretoyourpatient.Youwill seemoreexamplesofspecificityasyoulookatthesamplecareplansinthis manual. Eachoftheinterventionsyouplanhasacorrespondingrationale;ascientific explanationforwhythatnursingcaremeasureisappropriate.Beginninginyour secondsemesteryouwillberequiredtolistarationaleforeachofyour interventions.Manystudentsfindthistobeatediousandsomewhat superfluousstep.Iurgeyoutoexamineeachrationalecarefully,asitisan importantcomponentofyourlearning.Asnurses,itisessentialthatwe understandnotonlyhowwedothings,butwhywedothings.Rationalesreflect whatresearchhasproventobebestpractice.

Implementation
Implementationissimplycarryingouttheinterventionsyouhaveidentified asbeingnecessaryforyourpatientscare.PotterandPerry(2005)teachesthat preparationforimplementationensuresefficient,safe,andeffectivenursing care(p.344).Partofyourpreparationinvolveshavingathoroughcareplan completedbeforeyouarriveforclinical.Thisismandatory,andforgoodreason. Howelsewouldyouknowwhattodowith,andfor,yourpatient?Whenyou reportforclinical,youmustassess/reassessyourpatientinordertodetermine whetheryourplannednursinginterventionsarestillappropriateornecessaryfor thepatient.Implementationinvolvesmanystepsincluding,butnotlimitedto, directcare,counseling,teaching,andpreventionofcomplications.Awell thoughtoutandcomprehensivecareplanguidesyouthroughthesestepsand helpsyoupracticeefficiently,safely,andeffectively.

Evaluation
Thefinalstepinthenursingprocess,evaluation,allowsustodetermine whetherouruseofthenursingprocesswaseffective.Itasksthequestion,Did 3

thepatient(orthepatientscondition/wellbeing)improve?Eachnursing diagnosisyouidentifyhasspecificandmeasurabledesiredoutcomes. Evaluationisbasedonwhethertheexpectedoutcomeswereachieved,andnot onwhetherspecificinterventionswerecarriedoutorhelpful.Thisisan importantdistinctionandoneyouneedtounderstand.Forexample,adiagnosis ofImpairedPhysicalMobilitysuggeststhefollowingoutcomes: Patientwill(givespecifictimeframe): Increasephysicalactivity Verbalizefeelingsofincreasedstrengthandabilitytomove Demonstrateuseofadaptiveequipment(specifycrutches,walker, etc.)toincreasemobility Now,whilesomeofyourinterventionsforthisdiagnosiswillincludetreating thepatientspainbeforeactivity,usingagaitbeltwhileambulatingthepatient, andincreasingindependenceofADLs,evaluationisnotbasedonwhetherthese caremeasureswerecarriedoutsuccessfully.Rather,youwillbeevaluating whetherthenursingprocesswaseffectiveasawhole.Youwilldocument,on yourcareplan,whetheryoubelieveyourassessments,diagnoses,planning,and implementationmeasureswerecorrectandaccurate,andyouwillneedto providerationalestosupportyourposition.Rememberthatyourjudgments mustbebasedonwhetheryourpatientmet,orisprogressingtowards,the expectedoutcomes. Yourwrittenevaluationisaddedtoyourcareplanafteryouhavecompleted yourfirstdayofclinical.Basedonyourassessmentsandevaluations,youmay needtochangeyourprioritiesfordaytwo;someofyourdiagnosesmaystillbe pertinentwhileothersmayneedtobechanged.Payattentiontothispart:please resistthetemptationtoleaveyourtopfiveprioritiesunchangedsimplybecause youcangetawaywithit!Ihaveknownsomestudentswho,becausetheydid notwanttohavetoworkupanothernursingdiagnosis,wouldkeeptheirtop fiveinspiteofthefactthatchangingsomeofthemwouldhavebeenmore appropriate.Iunderstandthataddingmoreworktoyourcareplanafterhaving littlesleepandalongdayatclinicalisthelastthingyouwanttodo.However, trustmewhenIsaythatdoingjustthatcontributestoyourclinicaleducation andmasteryofthenursingprocess.Ifyoufailtobeconscientiousinthisarea youarecheatingyourselfandyourpatients. 4

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Section Two: Writing a Care Plan

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Hopefully,younowhaveabasicunderstandingofhowandwhyweusethe nursingprocessinordertoplancareforourpatients.NowIdliketoturnyour attentiontothemethodicalstepswetakeintheactualwritingofacareplan. Everyonehasauniquewritingprocess;fromgeneratingideas,organizingyour information,andwritingthebodyofyourworktorevisingandediting,the writingprocesscanvarybetweenindividuals.Iencourageyoutousethe processthatworksbestforyou.However,forthepurposesofthismanual,Iwill outlinetheprocessthatIfound,throughtrialanderror,tobethemostthorough andefficientforme.Bearinmindthatthisisonlyamodel,andnotaconcreteor mandatorywaytoaccomplishyourgoal.

GettingStarted
Youhavearrivedatyourclinicalsitetopickupyourassignment,dressed professionallyandwearingyourcrisp,whitelabcoat,lookingverymuchlikethe healthcareprovideryouaredestinedtobecome.Ifyouareafirstyearstudent, youareprobablyfeelingabitapprehensive,becauseyouareunfamiliarwiththe unittowhichyouhavebeenassigned,andyouarehesitantaboutenteringthe strangeandforbiddenoasisknownasthenursesstationandsimplyplucking yourpatientschartfromitsdesignatedspotor,worse,rightfromunderthenose ofthesecretary.(Donteverdothat,bytheway.Thesecretaryisakeeperof importantinformationandcanbeyourbestfriendorworstenemy.Alwaysask herpermissionbeforeremovingachartfromherdomain.)Takeadeepbreath andrelax.Goaheadandremovethechartyouneed,justbesuretoleaveanote initsspaceindicatingthatastudenthasthechartandwhereyouwillbeonthe unit.Thisisextremelyimportant,incasesomeonefromthemedicalteamshould needitforanyreason. Youarenowreadytofindaquietspotandbeginresearchingyourpatients medicalrecordinordertoobtaintheinformationyouneedtowriteyourcare plan.Haveanotebookready,andstartwriting. 5

DataCollectionandOrganization
First,letmewarnyouthatwritingyourcareplanmaytakeyoueight,ten,or eventwelvehours.Pleasedontbealarmed,asthisiscompletelynormal. Becausewritingyourcareplancanbesotimeconsuming,ithelpstoorganize yourdatainsuchawaythatmakesiteasytofindandrefertoonceyougethome andbegin.IfoundthatIsavedmyselfalotoftimebyorganizinginformationin alinearfashionthatparalleledtheformatofthecareplan.Here,Illsharewith youmymethod,thoughagain,bearinmindthatyouarenotobligatedtofollow myexample. BasicInformation Beginbywritingdownthefollowing:yourpatientsinitials,age,dateof admission,dateofsurgery(ifapplicable),admittingdiagnosis,codestatus,and anyallergies.Thisinformationwillbeincludedonthefirstpageofyourcare plan. Knowyourpatientsfullname,butdonoteverwriteitinyournotesoronyour careplan.Rememberthatallinformationisconfidentialandthatyouaretaking quiteabitofitoutofthehospitalandintoyourhome.Ifyournotesshould somehowbemisplaced,lost,stolen,orleftlyingsomeplacewhereothersmight readthemandthepatientsnameisonanypage,theirprivate,privileged informationwouldbecompromisedandyouwouldbeinviolationoftheHealth InformationPortabilityandAccountabilityAct(HIPAA).Pleasetakeevery conceivablemeasuretoprotectyourpatientsidentity. SignificantPastHistory(includingsocialhistory) Noteanyhealthissuesormedicaldiagnosesthatyourpatienthas(suchas diabetes,hypertension,coronaryarterydisease,emphysema,etc.)otherthanthat whichbroughtthemtothehospital.Listanyprevioussurgeries.Takedown theirsocialhistorysuchaswhotheylivewith,inwhattypeofhome,whether theyhavefamilyorothersourcesofsupportandcare,ifthereisanadvanced directiveinplaceand,ifso,whattype,anyculturalorreligiousconsiderations, andwhethertheysmokeorusealcoholorillegaldrugs. 6

ReasonforPresentAdmission Whyisthepatientinthehospital,howdidshecometobethere,andwhat washerconditionuponarrival?Yournoteshereshouldfocusonthedetails surroundingtheircurrenthospitalstay. SignificantEventsSinceAdmission Hereiswhereyouwillmakenoteofanysignificantornewfindingssincethe patientcametothehospital.Besuretolookupanydiagnosticssuchasxrays, ultrasounds,CTscans,MRIs,orEKGsandincludetheirfindings.Any complicationsthathavedeveloped,additionalsurgeries,ornewtreatments shouldalsobenoted. LaboratoryValues Makealistofallabnormallabvalues.Thosewithinnormalrangeshouldnot beincluded. Medications Makealistofallthepatientsmedications.Althoughthereisusuallya medicationlistinthechart,itisbettertoworkfromthepatientsmedication administrationsheet.Itletsyouknowwhichmedshavebeendiscontinuedor added,andismorecurrentthanthelistinthechart.Itmaybehelpfultomake twomedicationlists:oneforscheduledmedsandanotherforPRNs.These medsheetsarekeptindifferentlocationsatdifferentfacilities.Youwilllearn theirlocationonyourfirstvisittoyourassignedunit.Aswiththechart,always leaveanotethatyouhavethemedsheetsandwhereyouwillbeontheunit. Kardex TheKardexesarelocatedatthenursesstation,usuallynearthesecretary. Thisiswhereyouwillfindinformationaboutthepatientsdiet,permitted activity,IVfluids,whetherhehasacatheterinplace,ifheisonoxygen,typesof dressingsandscheduledchanges,andanytestshemaybescheduledfor.

ConductingResearch
Onceyouhaveallthenecessaryinformation,itstimetogohomeandbegin doingresearch.Again,yourpreferredwritingprocessshouldbeapplied.You 7

maychoosetodoallyourresearchbeforeyoubeginwriting,oryoumaydoitas youwrite.Eitherway,clearsomespacearoundyouandpreparetohaveseveral booksavailableatarmsreach. ResearchingYourPatientsCondition Youneedtohaveatleastabasicunderstandingofanymedicalconditionor surgeryaffectingyourpatient.Inyourfirstsemesterofnursingyouarerequired towriteout,verbatim,thedefinitionsofthesemedicalconditionsandsurgeries, citingyoursources.Inlatersemesters,youwilllikelypossessaknowledgebase aboutmostofthehealthcareissuesyouwillbedealingwithinclinical. However,whenyoudontknow,besuretolooktheissueupandunderstandit beforeyouwriteyourcareplanandreporttoclinical.Sourcesforthis informationincludeyourFundamentalsandMedicalSurgicaltextbooks,and MosbysMedicalDictionary. ResearchingNursingDiagnoses YourNursingDiagnosisHandbook,byBettyAckleyandGailLadwigisthe primarysourcefornursingdiagnoses.First,criticallythinkandtrytoidentify whatyourpatientsdiagnosesmightbe.Then,openupAckley,whereyouwill findanalphabeticallistofmedicalconditionsandsurgeries,andcommon nursingdiagnosesforeach.Asyouconsideradiagnosisforyourpatient,findit inAckleyandreaditsdefiningcharacteristicsandrelatedfactors.Simplydoing thatshouldletyouknowifthediagnosisisappropriateforyourpatient. Onceyouhavecompletedyourlistyouwillworkupyourtopdiagnoses. Thisincludeswritingoutallassessments,interventions,andrationales.Inyour firstyear,youarerequiredtociteyoursourceforthediagnosisandallrationales. Asmentionedpreviously,takethetimetoreadthrougheachintervention, chooseonlythosethatareappropriatefor,andmakethemspecificto,your patient. ResearchingLabsandDiagnosticTests Asofthiswriting,theresourceforthisinformationisAManualofLaboratory andDiagnosticTestsbyFrancesFischbach.Youwillutilizethisbooktoevaluate laboratoryvaluessuchasredbloodcellcount,hemoglobin,hematocrit,white bloodcellcount,urinalysis,electrolytes,etc.Itprovidesindicationsastowhya particularlabvaluemaybehighorlow.Inaddition,itoutlinesproceduresfor collectingspecimens.Diagnostictestsarealsoexplained,withinstructionsfor preparingthepatientfortestingandhowtocareforthemafterwards.Many 8

times,whenyoureadadiagnosticreportinthepatientschart,itwillprovidean interpretationofthefindings.Ifbyrarechancethisisnotthecase,youmaybe abletodiscernanexplanationinthetextbook.However,ifyouarenotsure whatthefindingsofadiagnostictestmaymean,donttrytoguess.Bringyour questiontoyourclinicalinstructor,whowillassistyouindeterminingthe significanceofanyfindings. ResearchingMedications YouwillresearchmedicationsinSpringhousesNursesDrugGuide.Foreach medicationonyourlistyouwillneedtoprovideitsgenericandtradename, dose,route,schedule,timesdue,pharmacologicalclass,therapeuticclass,mode ofaction(chemicaleffect),andsafedose.Inaddition,youmustprovidethe reasonthepatientistakingthemedication,potentialsideeffectsandinteractions, andallnursingresponsibilitiesrelatedtoadministeringthatmedication. Ifyouprepareyourcareplansonthecomputer,Istronglyrecommendthat youkeepadatabaseofeverymedicationthatyouresearchandwriteup.You willlikelyadministerseveralmedicationsrepeatedlythroughoutyourtwoyears innursingschool.Youwillsaveyourselfanincredibleamountoftimeifyou copyandpastethesemeds;youwillthenonlyneedtochangethedose,route, schedule,timesdueandreasonthepatientistakingthemed,asnecessary.Be advised,though,thatclinicalinstructorsfrownonthispractice.Theirconcernis thatyouarenotthoroughlypreparedtogivethemedicationandmaybe cheatingyourselfoutofvaluablelearningbyskippingtherepetitionoflooking upandwritingoutthemedeachtimeyouhavetogiveit.This,ofcourse,isa completelyvalidargument.However,asbusynursingstudentsyourtimeis valuableandyouneedtouseitaseffectivelyaspossible.Keepingadatabaseof medsisonewaytoaccomplishthat.Justdontdoitattheexpenseofyour patients.Bediligentandconscientiousandknoweverythingyouneedtoknow tosafelyadministerthatmedication.Yourpatientswellbeing,indeedtheir lives,dependsonyourdoingthat.Also,whencopyingandpasting,bearin mindthatyourinstructormayquizyouaboutthatdrug,andifshedoes,youd betterhavetheanswerstoherquestions.Ifyoudont,youmayearnyourselfa clinicalwarning. WritingUpDiagnoses,Interventions,andRationales Beginninginyoursecondsemesteryourcareplanwillhavethreecolumnsfor this.Inthefirstcolumnyouwillwriteyourdiagnosisintwoorthreeparts, dependingonyourinstructorspreference.Forexample,atwopartdiagnosis 9

wouldreadasfollows:ImbalancedNutrition,lessthanbodyrequirementsr/t lossofappetite.Thisstatesthediagnosisandthefactoritisrelatedto.Athree partdiagnosisdoesthesame,withtheadditionofstatingthedefining characteristics.Athreepartdiagnosis,then,wouldreadlikethis:Imbalanced Nutrition,lessthanbodyrequirementsr/tlossofappetitem/brecent30pound weightloss.Yournursingdiagnosisbookprovidesalistofrelatedfactorsand definingcharacteristicsforeachdiagnosis.Underyourdiagnosisyouwill providealistofsubjectiveandobjectivedatatosupportit. Themiddlecolumnisforlistingyourinterventions.Youwillberequiredto breakthemdownintothreesections,whichwilldifferinyourfirstandsecond year.Thismayseemabitconfusing,butwillbeexplainedandbecomeclear whenyoulookatthesamplecareplansprovidedinthismanual. Thethirdcolumnisforlistingtherationaleforeachintervention.Each interventionandcorrespondingrationaleshouldbenumberedandlineupnext tooneanotherineachcolumn.Thisorganizesyourcareplan,makesitneatand presentable,andsavesyourinstructorfromeyestrain.

EvaluatingYourPriorities(NUR51&52)
Afterthefirstdayofcaringforyourpatientyouwillberequiredtowritean evaluationoftheachievementofyourpriorities.Yourprioritiesfordayoneare yourtopnursingdiagnoses(threeinyourfirstyear,fiveinyoursecond). Evaluatingyourachievementrequiresyouthinkaboutwhetherthatdiagnosis wasaccurate,whyyoubelieveitwasorwasnot,andwhatyourplansare regardingthatdiagnosisfordaytwo.Shouldyoucometorealizethatoneof yourtopdiagnosesisnolongerappropriate,youwillneedtomoveothersupthe listorreplaceitwithanewdiagnosis.Youwill,ofcourse,havetowriteupthe interventionsandrationalesforanyadditionsorchangestothetoppriorities.

Revisions
Youmaymakerevisionstoyourcareplanatanytimebeforegivingittoyour instructor.Beprepared,though,tohanditoverattheendofyoursecond clinicalday.Hopefully,itisorganized,thorough,detailed,andaccurateand comesbacktoyouwiththewordSatisfactorywrittenacrossthetop.Ifit doesnt,dontbediscouraged.Mostinstructorswillallowyoutomakerevisions wheretheyhaveindicated,andifyoudothatandturnitbackintheywillaccept itandchangeittosatisfactory.Sometimes,evenafterrevisions,acareplanjust cantbesalvagedandyourinstructorwillnotacceptanymorechanges.Atthat point,youwillsimplyhavetoputthatcareplanbehindyouandputyourbest effortsintothenextone.

 Aswithanynewchallenge,whenyoufirstbeginwritingcareplansitmay takesometimetogetthingsexactlyright.However,witheachpassingweek therewillbeimprovementuntilyouarewritingcareplanswithconfidenceand ease.Asyouadvancethroughnursingschooltheacademiccurriculumand clinicalrequirementsbecomemorechallenging.However,althoughthepatients youcareforbecomemorecomplexand,therefore,thecareplansmore complicated,theyactuallybecomeeasiertowrite.Learningisbasedonprevious knowledgeandexperience,andasyouprogressthroughnursingschoolyouwill findyourselfassimilatingdatamorequicklyandefficiently,andcompletingyour careplansinamoretimelymanner.Everyonestartsoutslowly,buttime, practice,andexperiencewillhaveyouwritingcareplansthatnotonlyprovidea mapofcareforyourpatients,buthelpyougrowasaproviderofthatcareinthe professionofnursing. 11

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Section Three: Sample Care Plans

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InthissectionyouwillfindsamplesofcareplansforNursing11 (FundamentalsofNursing)andNursing51and52(NursingCareoftheAdult). IregretthatIcouldnotincludesamplecareplansforNursing12(ParentChild Nursing).Asyouwillsoonlearn,ifyouhaventalready,obstetricsand pediatricsarespecializedareasandtheprocessofwritingcareplansand obtaininginformationforthemisvastlydifferentfromthatwhichIhave outlinedhere.However,therearecopiesofobstetric(laboranddelivery, postpartum,andnewborn)andpediatriccareplansavailableforreviewinthe writinglab. Fundamentals:Nursing11CarePlans WhatfollowsisasampleofaNursing11careplan,whichconsistsofthree phases.Asyousuccessfullycompleteonephase,youwillmoveontothenext, untilyouarewritingacompletecareplan.Inthesample,Ihaveindicatedon eachpagewhichphaseitispartof. Asyouwillsee,pageoneconsistsofblockswhichareselfexplanatory.You willsimplyneedtofilltheminwiththeappropriateinformation. Pagetwolistsallyourpatientsdiagnosesandsurgeriesanddefinesthem Themedicationpagelistsallmedicationsthepatientistaking.Ihave workeduponlytwo,foryoutouseasamodel. Next,thereisapagerequiringyoutolistyourtopthreenursingdiagnosesfor eachdaythatyouwillbeprovidingcare,andasectionforprovidingsocio culturalinformation. Finally,thereisasampleofanursingdiagnosisanditsinterventions.Asyou willsee,yourinterventionsmustbebrokendownintothreesections: Assessments,Interventions,andTeaching.Someinformationmayberepeatedin morethanonesection,whichisacceptable.Again,Ihaveworkeduponlyone diagnosis.Followingthemodelprovided,youshouldhavenodifficulty completingallthreeofyourrequireddiagnoses. 12

BristolCommunityCollege NUR11:NURSINGCAREPLANPHASEI
Student name: Rm. # Physician I: Nurse Code status Precautions Allergies Secondary Diagnoses O: Wednesday I: O: Treatments/ Procedures Specimens to obtain & Diagnostic List the materials needed and any procedures to be done on your time procedure steps T P R B/ P Wednesday T P R B/ P Vital Signs Activity Hygiene Patient initials: Diet Clinical Date Tuesday/ Findings Assessments LOC, Mental S tatus, Orientation Pain Assessment Lung S ounds O2 S aturation Bowel S ounds (Assess all 4 quadrants) Last BM Extremities (Pulses, CMS , Homan's)

Admitting Diagnosis

I&O Tuesday

Wednesday/ Findings

Tuesday

Neurological Checks (PERRLA) IV Therapy Assessments S ite Flow Complications Other Medications List all medications that you will administer & times due olution and Rate) IV Therapy (S S cheduled Medications S TAT or One Time PRN Medications

DefinitionofMedicalDiagnosesandSurgery

AdmittingDiagnosis RenalFailure:theinabilityofthekidneytoexcretewastes,concentrateurine,andconserveelectrolytes.Thecondition maybeacuteorchronic(MosbysMedicalDictionary,p.1485). Citeyoursource! SecondaryDiagnoses Angina:aparoxysmalthoracicpaincausedmostoftenbymyocardialanoxiaasaresultofatherosclerosisorspasmofthe coronaryarteries.Thepainusuallyradiatesalongtheneck,jaw,andshoulderanddowntheinneraspectoftheleftarm. Attacksofanginapectorisareoftenrelatedtoexertion,emotionalstress,eating,andexposuretointensecold.Thepain mayberelievedbyrestandvasodilationofthecoronaryarteriesbymedication(Mosby,p.96) Arthritis:aninflammatoryconditionofthejoints,characterizedbypain,swelling,heat,redness,andlimitationof movement(Mosby,p.136) AtrialFibrillation:acardiacarrhythmiacharacterizedbydisorganizedelectricalactivityintheatriaaccompaniedbyan irregularventricularresponsethatisusuallyrapid(Mosby,p.154) CongestiveHeartFailure:anabnormalconditionthatreflectsimpairedcardiacpumping.Itscausesincludemyocardial infarction,ischemicheartdisease,andcardiomyopathy(Mosby,p.416). SickSinusSyndrome(SSS):acomplexofarrhythmiasassociatedwithsinusnodedysfunction.Theconditionmay resultfromavarietyofcardiacdiseases,rangingfromcardiomyopathiestoinflammatorymyocardialdisease.Itismost commonlyrelatedtoeitherintermittentSAblockorinadequateSAconduction.SickSinusSyndromeischaracterizedby severesinusbradycardia,eitheraloneoralternatingwithtachycardia,oraccompaniedbyatrioventricularblock.The mostcommonsymptomsarelethargy,weakness,lightheadedness,dizziness,andsyncope(Mosby,p.1580). Surgeries Pacemaker:electricalapparatususedtoincreasetheheartrateinseverebradycardiabyelectricallystimulatingtheheart muscle(Mosby,p.1259). THISPAGEISINCLUDEDINPHASEONE14

NURSING11CAREPLANPHASETWO Medications
Nameofdrug Dose Route Timesdue Classifications SafeDose spironalactoneAldactone 25mg PO2xdaily Generic and trade names 0800/2000 Pharmacologicalclass: potassiumsparingdiuretic Therapeuticclass: managementofedema, antihypertensive,diagnosisof primaryhyperaldosteronism, treatmentofdiureticinduced hypokalemia Safedose:upto100mgdaily potassiumchlorideKTab 20mEq POdaily 0800 Pharmacologicalclass: potassiumsupplement Therapeuticclass:mineral Safedose:upto50mEqtwice daily DrugAction Reasonpatientison medication(bespecific) Drugaction:antagonizes aldosteroneindistaltubule; promoteswaterandsodium excretionandhinders potassiumexcretion,lowers bloodpressure,andhelpsto diagnoseprimary hyperaldosteronism Reasonptisonmed:totreat hypertension Number all nursing actions. You will find these listed with each med under nursing process Drugaction:aidsin transmittingnerveimpulses, contractingcardiacand skeletalmuscles,and maintainingintracellular tonicity,cellularmetabolism, acidbasebalance,andnormal renalfunction.Replacesand maintainspotassiumlevels. Reasonptisonmed:CHF Note that there may be an interaction between these meds. You may want to emphasize this in red, or by marking it with a highlighter

Meds are part of phase 2

List3sideeffects Listallsignificantnursing actionsrelatedtothe administrationofthismed Observeforheadache, diarrhea,dehydration Always preface side effects with observe for 1.Givedrugwithmealsto enhanceabsorption 2.Protectdrugfromlight 3.Monitorelectrolytelevels, fluidintakeandoutput,and BPqshift(0800/1600/2400) 4.Bealertforadverse reactionssuchas hyperkalemia,angioedema, confusion,anddrowsiness 5.Bealertfordrug interactionssuchaspotassium chloride ObserveforEKGchanges, abdominalpain,weaknessof limbs 1.Givecautiously;differentK supplementsdelivervarying amountsofK.Neverswitch productswithouta prescribersorder 2.Givewithoraftermeals withafullglassofwater 3.Makesurepowdersare completelydissolved 4.Monitorrenalfunction,fluid intakeandoutput 5.MayinteractwithKsparing diuretics

NUR11NURSINGCAREPLAN THREEMOSTIMPORTANTNURSINGDIAGNOSES IncludepagenumberfromNUR11requirednursingdiagnosisbook

Tuesday 1. Oxygenation:DecreasedCardiacOutputr/tdysrhythmia(p.136) 2. Elimination:ImpairedUrinaryEliminationr/tdiuretictherapy(p.787) 3. Safety:ImpairedSkinIntegrityr/tprolongedimmobility(p.584)

Category of basic human needs Diagnosis Related to (what is causing this problem) Cite page number

Wednesday 1. Your diagnoses may remain the same or, after you have 2. reassessed the patient, change for day 2. 3. ImplicationsforNursingCareRelatedtoCulturalBackground
(considerlanguage,religion,ethnicity,andsocialorganization)

PatientisEnglishspeakingandlivesaloneinasinglestoryhouseandreceives mealsdailyfromMealsonWheels.Sheisaretirednurseandisactiveinher community.SheisadevoutRomanCatholicandattendsMassregularly. THISISPARTOFPHASETWO 16

NursingDiagnosis DecreasedCardiac Outputr/tdysrhythmia (Carpenito,p.136)

NursingInterventions Assessments 1. Assessrateandqualityofapicalandperipheralpulsesqshift @0800,1600,2400 2. AssessBPandanyorthostaticchangesqshift@0800,1600, 2400,andbeforeambulatingpatient 3. Assesslungsoundsqshift@0800,1600,2400.Noteany occurrenceoforthopnea 4. Assessforcomplaintsoffatigueandreducedactivity tolerance.Determinewhatlevelofactivitycausesfatigueor exertionaldyspnea 5. Assessurineoutputqshift@0800,1600,2400 6. Assessforanychangesinmentalstatuswhileperforming neurochecksqshift@0800,1600,2400 7. Assessoxygensaturationwithpulseoximetryqshift@0800, 1600,2400andduringactivity Interventions 1. Monitorandrecordintakeandoutputqshift@0800,1600, 2400 2. Monitorforsymptomsofheartfailureanddecreasedcardiac output;listentoheartandlungsounds;noteanyorthopnea, dyspnea,fatigue,weakness,adventitiouslungsoundssuch ascracklesorrales 3. Observeforchestpainordiscomfort;notelocation,radiation, severity,quality,duration,andassociatedmanifestations suchasnausea,indigestion,anddiaphoresis;alsonote precipitatingandrelievingfactors. 4. MonitorlabworksuchasCBC,sodium,potassium,and creatininelevel 5. Graduallyincreaseactivitywhenthepatientsconditionis stabilizedbyencouragingslowpacedorshortperiodsof activitywithfrequentrest:observeforsymptomsof intolerance a) TakeBPandpulsebeforeandafteractivityandnote changes 6. Monitorbowelfunction.Administercolace100mgPOdaily @0800,asprescribed a) Cautionpatientnottostrainwhendefecating b) Haveherusethecommodefortoiletingandavoiduseof bedpan 7. Observeforsyncope,dizziness,palpitations,orfeelingsof weaknessassociatedwithanirregularheartrhythm 8. Administerspironolactone25mgPO@0800;potassium chloride20mEqPO@0800asprescribed 9. Observeforsideeffectsfromcardiacmedications Teaching 1. Teachstressreductiontechniquessuchasguidedimagery,

List all assessments you will perform. Be specific about times.

List the specific labs you will monitor

List specific meds related to this diagnosis

2. Reference to volunteer work is specific to this patient.

3.

4. 5. 6.

controlledbreathing,musclerelaxation Explainnecessaryrestrictions,includingtheneedfora sodiumrestricteddiet,guidelinesonfluidintake,andthe avoidanceoftheValsalvamaneuver Teachtheimportanceofpacingactivities,includingvolunteer work,andtheneedtorestbetweenactivitiestoprevent becomingoverfatigued Teachherabouttheactions,sideeffects,andimportanceof takingcardiovascularmedications Providespecificwrittenmaterialsandselfcareplanforher, orhercaregivers,touseasareference Instructherontheimportanceofgettingapneumonia vaccine(usuallyonceperlifetime)andfluvaccines(yearly) asprescribedbyherphysician

THISISINCLUDEDINPHASETHREE 18

MedSurg:Nursing51&52CarePlans Followingisasampleofanursing51medicalsurgicalcareplan.Youwill noticethatitcontainsmoreextensiveinformationthantheNUR11careplanand isquitedifferentinformatfromtheOBandpediatriccareplans. AswithNUR11,yourinterventionsmustbebrokendownintosections. However,formedsurgtheyshouldappearasfollows:Assess,Prevent,and Evaluate.UnderAssessyouwilllist,ofcourse,allnecessaryassessmentsforthat diagnosis.UnderPrevent,listallinterventionsyouplantoperforminorderto preventfurtherdeteriorationof,andhopefullyimprove,yourpatientscondition andwellbeing.UnderEvaluateyouwilllisttheexpectedoutcomesforyour diagnosis. Inordertogiveyouacomprehensivepictureofwhatyourcareplanshould looklike,thesampleIhaveprovidedispresentedinitsentirety. 19

 BRISTOLCOMMUNITYCOLLEGE FallRiver,MA CAREPLAN NUR51&52

Name: Date: AdmissionDate: Patientsinitials: Age:44 Allergies:morphine, cephalosporins Diagnosis:cellulitis,Lupperthigh Surgery:N/A Dateofsurgery:N/A

SignificantPastHistory(includingsocialhistory) Patientisamarried44y/ofemale.Historyrevealsarecentcervicalspineinfection resultinginafractureandsubsequentquadriplegia.Thecspineinfectionisspeculated tohavearisenfromanundiagnosedcystwhichburst.Patienthadalonghospitalization followedbyrecuperationat______________NursingHome,whereshehasbeen residingforthelast2months.Herhusbandisdisabledandtheyrecentlylosttheir home,duetotheirrespectivemedicalconditionsandfinancialhardship.Their2 adolescentchildrenarestayingwithrelatives.Thereisadistanthxofdrugabusewhich predatesthecspineinfectionbyseveralyears.Patientidentifiesherreligionas Catholic.Sheisafullcode,astherearenoadvancedirectivesinplaceatthistime. ReasonforPresentAdmission Patienthaspressureulcersonbothshoulderblades,coccyx,andRhip.Herlefthipand theanteriorandlateralaspectsoftheLthigharered,edematous,andwarmtothe touch.Shewascomplainingofneckspasms,morepronouncedontheleftthantheright. Shedevelopedafever,hermentalstatusappearedtodeteriorateandshewasbroughtto theERat__________Hospital.Hertemperaturewasrecordedat103.5.Alumbar puncturewasperformed;theresultswerenegativeformeningitis.Shecomplainsofnot feelingwell,andbeingachyalloverx34days.Thereissomedistensionofthe abdomen,buttherehavebeennochangesinbowelhabits.Diagnosisiscellulitisofthe Lupperthigh. D5NS@100cc/hr This information will be found on the Kardex. There is not a specific place for Foleycatheter it on your care plan, so you may write it Regulardiet in anywhere. FlushGtubewith30ccH2Obeforeandaftermeds TIP: orders and treatments such as these can change at any time it is best Coccyx:aquagelwith1rollofgauze,coverwithDSD to re-check the Kardex on the morning of clinical, and write these on your care plan when you come in, rather than typing them in the night before.

SignificantEventsSinceAdmission Date:CXRrevealscephalizationwithinterstitialopacities.Mayreflectvolumeoverload orunderlyinginterstitiallungdisease.Nopleuraleffusion,consolidationor pneumothorax. Date:AttempttoinsertPICClinetoleftantecubitalregionunsuccessfulafter3attempts. NursetoconsultwithMDaboutalternativeoptions Date:Patientcompletedassessmentformsforpainclinic.Awaitingassessmentby woundclinicandPT/OT Date:TriplelumencentrallineplacedRUC.PlacementcheckedbyportableCXR This section consists of the findings of your head-toe physical assessment. SummaryofPatientStatusatEndofDay1
Vitalsigns:0700101.3771694/5995%RA 1130101.1751789/5497%RA

Patientalert&orientedx3formostoftheday,withperiodicnaps.Lungsareclearbilaterally; abdomensoftwithpositivebowelsoundsx4quadrants.Calvesappearnormalwithnoredness, edema,orwarmth;positivebilateralpedalpulses.Thereisasmallareaofrednessonthetipof theRgreattoe,whichIoutlinedwithmarker,nursemadeaware.Heelsintactwithnoredness. Skinisdrywithsomeflaking.Lipsaredry,butinspectionoftheoralmucousmembranesshows adequatemoistureandnolesions.ThereismarkedrednessandheatovertheLhipandthe anteriolateralaspectoftheLupperthighrelatedtothecellulitis.Entireareacircledbynurse,in ordertoevaluateanyrecessionorprogression.Woundtococcyxnotinspected,aspatientis awaitingaconsultfromthewoundclinic.Dry,sterile4x4replacedover1cmcircularwoundon Rshoulderblade;someserosanguinousdrainagepresent.Patientc/odiscomfortofherneckand back;performedfrequentpositionchanges,takingcaretoensureproperbodyalignment.Area aroundFoleycatheterinspectedandcleaned;noredness,edema,dischargeorodorpresent.IV siteonRhandpatent.Patientc/oburninganditchingwhileUnasynbeinginfused.Site inspectedbynurse;nochangeoftemperatureorcolorofskin,noedema.Infusionslowedand warmpackappliedtosite.Patientate100%ofbreakfast,30%oflunch.POfluidintakewas approximately860ccs.Urineoutputof450ccs(64cc/hr),appearanceyellowandconcentrated. Patienthad1largebowelmovementmidmorning.Afternoonvitalsrevealedpatienttobe febrile@101.1withaBPof89/54.NursemadeawareandinformedmethatBPconsistentlyruns low.AnorderforTylenol1000mgPOq6hourswaswrittentoday. Day2: Vitals:070099.78020102/6996%RA Your day 2 vitals and any new treatments will be written in by hand 110098.77418122/6996%RA before you pass in your care plan Vancomycin:peak32.6,trough8.0 Woundcareconsult:treatmentplanistochangedsgtococcyx2xday.IrrigatewithsterileH2O, coatpackingwithtripleantibiotic,coverwithDSD.

Youshouldalsolistyourday2labs!

21

In order of priority; may change for day 2

PriorityNursingDiagnosisObjectiveTestData Test&Norms Results& Interpretation W TH

Dates

1 2 3 4 5 6 7 8 9 10 11

1 2 3 4 5 6 7 8 9 10 11

ImpairedSkinIntegrityr/t Sodium immobility,pressure 135145 RiskforInfectionr/topen wounds Chloride 96107 RiskforIneffectiveTissue Perfusion,peripheralr/t Potassium 3.55 interruptedvenousflow secondarytoprolonged immobility Glucose Powerlessnessr/tlossoffunction 70110 ChronicSorrowr/tpermanent BUN 821 disability ChronicPainr/tdiseaseprocess Creatinine 0.51.2 DisturbedBodyImager/ttrauma (quadriplegia) Prealbumin 1836 IneffectiveProtectionr/t abnormalbloodprofile(seelabs) Protein(CSF) 1545 ImpairedBedMobilityr/tneuro muscularimpairment (classificationlevel4:doesnot WBC participateinactivity) 311 ImbalancedNutrition,lessthan MCV bodyrequirementsr/tlossof 8296 appetite(wgt:125lbsBMI:20.2) Neutrophils SelfcareDeficit, Include specifics 4283% bathing/hygiene, dressing/grooming,toiletingr/t Lymphocytes neuromuscularimpairment 1347%

213:131 214:135 213:96 214:102 214:3.2 213:121 213:5 214:5 213:0.4 214:0.3 213:17.7 213:45.8 213:15.4 214:7.3 213:80.2 214:81.7 213:88% 213:5% 214:6.9%

Slightlydecreaseddueto sweating(febrilex3 days),deficientdietary intake Slightlydecreasedwith sodiumloss Slightlydecreasedto sweating,draining wounds,inadequate dietaryintake Slightlyelevated;maybe r/tmeds Decreased;maybedueto lowproteinintake, malnutrition Decreasedduetolow protein,decreased musclemass, malnutrition Decreasedduetolow protein,malnutrition Notsignificant.Level mustbemoderatelyto markedlyincreasedto suggestinfection Acuteinfection(cellulitis) RBCsareslightly microcytic Acute,localizedinfection, inflammation Decreased;maybedueto debilitatingillness

12 13 14 15

12 13 14 15

SexualDysfunctionr/taltered bodyfunction DeficientDiversionalActivityr/t disability,environment RiskforAutonomicDysreflexia r/tspinalinjury

RiskforDisuseSyndromer/t paralysis

UrinepH 56 RBC 3.965.27 HGB 11.615.5 HCT 3547

213:>9 214:3.78 214:10.5 214:30.9

Mayber/tpotassiumloss Relatedtoirondeficiency Duetoanemia Indicatesanemia.Likely irondeficient(if microcytic,RBCsand HCTdonotparallel)

Although not required, you may want to type lab values in a different color, or mark them with a highlighter to help them stand out for easy reference.

23

NursingPrioritiesforDay1 ImpairedSkinIntegrityr/t immobility,pressureonbony prominences Evaluate whether your diagnosis was, or was not, appropriate, and why RiskforInfectionr/topen wounds RiskforIneffectiveTissue Perfusion,peripheralr/t interruptedvenousflow secondarytoprolonged immobility Powerlessnessr/tlossof function

EvaluationofPriorityAchievement Thiswasanaccuratediagnosisand importantpriority.Patienthasan openwoundonthecoccyx,and woundsonbothshoulderblades. Herimmobilitypresentsachallenge inthatitmaybedifficulttopromote healingandpreventnewwounds, astheptisalmostconstantlyonher back. Patientatincreasedriskfor infectionofherwounds,particular lytheoneonhercoccyxduetoits depthandproximitytotheanus (sheisoccasionallyincontinentof stool) Iamnotentirelyconfidentthatthis diagnosisisatop5priority.There areotherswhichcouldeasilymove upthelist.Patientisbeingtreated withLovenox40mgSCdaily; however,sheisunabletoperform ROMexercises,andtheabsenceof compressionstockingsconcernsme. DevelopmentofaDVTand progressiontoapulmonary embolismisarealdanger... symptomscoulddevelopsilently,as theptisunabletoreportchangesin sensation Powerlessnessisahugeissuewith thispt.Shedemonstratesbehaviors atthelow,moderate,andsevere level.Herlackoffunctionisonly onecontributingfactor(sheis completelydependentonothersfor care).Anequalportionisdirectly relatedtoherperceivedlackof controloverdecisionsandwhat happenstoher.Shehasbeen

NursingPrioritiesforDay2 Thisremainsapriorityat#1. Iwouldliketoviewand measureherexisting wounds,ifthewound consultanthasnotdoneso (ptdueforconsultonday one,afterIleft) Thisdiagnosisremainsat#2, forthereasonsstated.Iwill checkherfrequentlyfor incontinenceandcleanher promptlytoavoid contaminationofherwound Iwillkeepthisdiagnosisat #3,abovepowerlessnessand chronicsorrow,onlybecause itispotentiallylife threatening.Iwillspeakto herprimarynurseabout obtaininganorderforTEDS orpneumaticstockings If your diagnosis remains the same, what do you plan to do for the pt on day 2? If it changes, list the new one in this column and provide a rationale for the change Thisdiagnosisremainsat#4. Iwouldliketoinitiatea consultwithapsychiatric nurseaswellasmake inquiriesaboutherpossible optionsforadifferentcare facility(shementioneda facilitywhereshefeltbetter caredfor).

 ChronicSorrowr/t permanentdisability

unsuccessfulinherattemptstogain informationabouthertreatment goalsanddischargeplans, particularlyasitappliestothe nursinghomewhereshecurrently resides.Shefeelsignoredand seemsresignedthatitisuselessto attempttogaininformation.She appearstohaveanexternallocusof control. Patientexhibitsbehaviorsconsistent withthisdiagnosis.Shehasperiods ofsadness,crying,anger, frustration,apathy,etc.Im concernedthatsheissufferingfrom majorclinicaldepression.

Thisdiagnosisstaysat#5.I wouldliketoexplorewith thepatientherfeelingsabout counseling/medicationfor depression.Iwonderifa combinationofconsistent cognitivebehavioraltherapy andantidepressant medicationmightpromote readinessforenhanced coping.

25

MedicationOrder fentanyl patch Duragesic 100 mcg transdermal q 3 days Opioid analgesic Anesthetic MOA: may bind with opioid receptors in CNS, altering both the perception of and emotional response to pain Patient is taking these types of meds also list in another color or mark with a highlighter! Safe dose: 100 mcg per hour

Rationaleforuseinthis patient For pain relief May interact with: CNS depressants, other opioid analgesics, diazepam (CV depression may occur) Side effects: confusion, hallucinations, arrhythmias, bradycardia, dry mouth, urine retention, respiratory depression, apnea

NursingCareMeasures 1.Monitor bladder function, respiratory rate and depth, and O2 saturation 2. Report respirations of <12/minute, O2 sat of <95% Notice that any teaching r/t applying the fentanyl patch has not been included patient is a quadriplegic and unable to apply it herself. Teaching would be directed at family/caregivers, if appropriate

zinc sulfate Zinca-Pak 220 mg PO daily Trace element Nutritional agent MOA: participates in synthesis and stabilization of proteins and nucleic acids in subcellular and membrane transport systems Safe dose: 660 mg daily enoxaparin sodium Lovenox 40 mg SC daily Low-molecular-weight heparin derivative Anticoagulant MOA: accelerates formation of antithrombin IIIB-thrombin complex and deactivates thrombin, preventing conversion of fibrinogen to fibrin. Has higher antifactor Xa-antifactor IIa activity ratio Safe dose: 40 mg SC once daily for 611 days; up to 14 days can be tolerated lorazepam Ativan 0.5 mg PO 3X daily Benzodiazepine, sedative hypnotic, antianxiety agent, anticonvulsant, skeletal muscle relaxant, antiemetic MOA: inhibits ability to recall events. Interacts with GANA-benzodiazepine receptor complex in the brain Safe dose: up to 10 mg daily

To promote healing of wounds No significant interactions Side effects: N/V

1.Monitor serum zinc levels. Normal range is 0.05 0.15 mg/dL

To prevent DVT, pulmonary embolism Side effects: peripheral edema, CV toxicity, hypochromic anemia, thrombocytopenia, hemorrhage, bleeding complications, redness/irritation at injection site

For severe overdose, give protamine sulfate by slow IV infusion at concentration of 1% to equal dosage of enoxaparin injected 1.Monitor platelet count 2. To avoid drug loss do not expel air bubble from 30- or 40-mg prefilled syringes 3.Do not massage after SC injection. Rotate sites among the L and R anterolateral and the L and R posterolateral abdominal walls 4.Monitor pt for s/s of bleeding 1.Monitor liver, kidney, and hematapoietic function periodically

To prevent/reduce anxiety May interact with other CNS depressants Side effects: airway obstruction, apnea, blurred vision, confusion, crying, delirium, depression, excessive drowsiness, hypotension, respiratory depression, hypotonia,

Generic name not capitalized pantoprazole sodium Protonix 40 mg PO daily Proton pump inhibitor, gastric acid suppressant MOA: inhibits the activity of the proton pump by binding to hydrogenpotassium adenosine triphosphate, located at secretory surface of the gastric parietal cells. Suppresses gastric acid secretion Safe dose: 40 mg daily x8 weeks docusate sodium Colace 100 mg PO 2X daily Emollient laxative MOA: reduces surface tnsion of interfacing liquid contents of bowel; promotes additional liquid into stool, thus forming a softer mass Safe dose: up to 360 mg daily ascorbic acid Vitamin C 500 mg PO daily Water-soluble vitamin MOA: stimulates collagen formation and tissue repair; involved in oxidation-reduction reactions throughout the body Safe dose: up to 500 mg daily for patients with delayed wound healing levothyroxine Synthroid 125 mcg PO daily Thyroid hormone replacement MOA: not fully defined; stimulates metabolism by accelerating cellular oxidation Safe dose: up to 200 mcg daily vancomycin HCl Vancocin 1 GM IV in NS q 12 hours Glycopeptides Antibiotic MOA: hinders bacterial cell wall synthesis, damaging bacterial plasma membrane and making cell more vulnerable to osmotic pressure Safe dose: up to 1000 mg q 12 hours (2000 mg daily) To treat staph infection (cellulitis of L upper thigh) Patients specific infection. IV Administration Dilute in 200 ml NS Infuse over 60 minutes Do not infuse with any other medications Always include instructions for giving a med intravenously 1.Monitor peaks and troughs 2.Monitor site for phlebitis/irritation/ infiltration/extravasation To treat hypothyroidism Side effects: tachycardia, palpitations, HTN, dysphagia, 1.Monitor TSH levels 2.Give drug at the same time each day, to keep hormone level constant 3.Instruct pt to immediately report chest pain, palpitations, sweating, or shortness of breath To promote healing Side effects: diarrhea, acid urine, renal calculi 1.Give PO solution directly into mouth or mix with food 2.Teach patient about dietary sources of Vitamin C To treat GERD Side effects: headache, insomnia, asthenia, migraine, anxiety, dizziness, diarrhea, abd. pain, constipation, urinary frequency, UTI, back pain, neck pain, bronchitis, increased cough 1.Monitor for signs of epigastric or abdominal pain, and for blood in stool or emesis 2. Tablet must be swallowed whole and not crushed, split, or chewed 3.Give with or without food

To prevent/relieve constipation Side effects: mild cramping, diarrhea

1.Teach patient about maintaining adequate fluid and fiber intake

Side effects: tinnitus, ototoxicity, nephrotoxicity, wheezing, dyspnea, red man syndrome

ampicillin sodium (1GM) and sulbactam sodium (0.5GM) Unasyn 1.5 GM IV q 6 hours Aminopenicillin and beta-lactamase inhibitor Antibiotic MOA: ampicillin inhibits cell-wall synthesis during microorganism multiplication; sulbactam inactivates bacterial beta-lactamase, the enzyme that inactivates ampicillin and provides bacterial resistance to it Safe dose: up to 3GM q 6 hours (12 GM daily) oxycodone CR 40 mg PO q 8 hours Opioid analgesic MOA: same as fentanyl Safe dose: up to 80 mg q 12 hours

To treat skin structure infection (cellulitis of L thigh) Patient did experience vein irritation; because of my med research, I was prepared for this possibility. See summary of pt status at end of day 1. Side effects: vein irritation, thrombophlebitis, anemia, thrombocytopenia, thrombocytopenic purpura, leukopenia, agranulocytosis For moderate to severe pain May interact with: other opioid analgesics (fentanyl) Side effects: hypotension, bradycardia, constipation, ileus, urine retention, respiratory depression Multivitamins are prescribed for patients who need extra vitamins, who cannot eat enough food to obtain the required vitamins, or who cannot receive the full benefit of the vitamins contained in the food they eat To treat depression Side effects: confusion, tachycardia, dry mouth, taste perversion, upper respiratory infection, increased sweating

IV Administration Reconstitute with: NS, D5W, or LR Allow to stand a few minutes to allow foam to dissipate Inject over 10-15 minutes or dilute in 50100 ml of a compatible dilutent and infuse over 15-30 minutes Change site q 48 hours Do not add or mix with other drugs

1.Monitor rate and depth of respirations; if <12, report immediately 2.Give with food or milk to prevent GI upset 3.Assess pain using a pain rating scale before and after administration

multivitamin 1 cap PO daily Nutritional supplement

citalopram hydrobromide Celexa 40 mg PO daily SSRI MOA: may enhance serotonergic activity in CNS by inhibiting neuronal reuptake of serotonin Safe dose: up to 40 mg daily

1.Monitor VS regularly for signs of decreased BP or tachycardia

28

MedicationOrder

Rationaleforuseinthis patient

NursingCareMeasures

PRNs
diazepam Valium 1 mg PO q 6 hours prn Benzodiazepine Anxiolytic, skeletal muscle relaxant, anticonvulsant, sedative-hypnotic MOA: may depress CNS at limbic and subcortical levels of brain; suppresses spread of seizure activity produced by epileptogenic foci in cortex, thalamus, and limbic system Safe dose: up to 40 mg daily acetaminophen Tylenol 650 mg PO q 6 hours prn Non-opioid analgesic MOA: analgesic effects by blocking prostaglandins or pain receptor sensitizers May relieve fever by acting in hypothalamic heat regulating center Relieves pain and fever Safe dose: up to 4000 mg daily oxycodone HCl OxyContin 10 mg PO q 4 hours prn OR 5 mg PO q 4 hours prn Opioid analgesic MOA: same as fentanyl, oxycodone CR Safe dose: 5 mg q 6 hours (20 mg/24 hours) This dose is not safe (pt may have tolerance) For moderate to severe pain May interact with: CNS depressants Side effects: hypotension, bradycardia, constipation, ileus, urine retention, respiratory depression Nursing actions same as for oxycodone CR To treat anxiety or muscle spasms May interact with: CNS depressants Side effects: hangover, ataxia, psychosis, tremors, bradycardia, CV collapse, diplopia, urine retention, respiratory depression, desquamation As needed for discomfort or fever Side effects: neutropenia, leukopenia, thrombocytopenia, liver damage, hypoglycemia, jaundice Antidote: acetylcysteine initially 140 mg/kg PO followed by 70 mg/kg PO q 4 hours for 17 doses 1.Carefully monitor all sources of acetaminophen to ensure that administration does not exceed 4000 mg daily 1.Monitor pulse and rate and depth of Respirations 2.Report pulse <60 or respirations <12

29

PRIORITYDIAGNOSES ImpairedSkinIntegrityr/t immobility,pressureover bonyprominences Subjective/Objectivedata: Redness,moisture,broken skin,openareas,drainage These are the s/s that you directly observe or that are reported by the patient

NURSINGINTERVENTIONS Assess 1.Site(s)ofskinimpairmentatleastoncedailyforsignsof infection(colorchanges,redness,warmth,swelling, exudate,odor) 2.Patientscontinencestatus 3.Nutritionalstatus(weight,calories,protein,CHO,fats, vitamins,minerals,prealbumin) Prevent 1.Measuresizeanddepthofwound.Determinethat impairmentinvolvesskindamageonly.ClassifyasStage IorII 2.Minimizeexposureofskinimpairmentandotherareasto moisturefromincontinence,perspiration,orwound drainage 3.InitiateaPTconsulttoconductariskassessmenttoolto systematicallyassessimmobilityrelatedriskfactors 4.Avoidpositioningpatientonsiteofimpairment(coccyx) 5.Turnandrepositionq2hours

RATIONALES 1.Systematicinspectioncanidentifyimpending problemsearly Citations not required in NUR 51 2.Moisturefromincontinencecontributestopressure ulcerdevelopmentbymaceratingtheskin 3.Optimizingnutritionalintakeisneededtopromote woundhealing 1.Establishesabaselineforcomparisonwhenevaluating healing 2.Moisturecontributestopressureulcerdevelopmentby maceratingtheskin 3.AvalidatedriskassessmenttoolsuchastheNortonor Bradenscaleshouldbeusedtoidentifypatientsatrisk forimmobilityrelatedbreakdownandtohelpguidethe planofpreventionandcare 4.Createspressureandinterfereswithperfusion 5.Alternatessitesofpressurereliefandkeepsthepatient

 Physicians specific order for dressing changes Expected outcome

6.Transferpatientwithcaretoavoidexternalmechanical forces(pressure,friction,shear) 7.MaintainHOBatlowestpossibledegreeofelevation 8.Useliftdevices,pillows,foamwedgestoassistpatient withmovingandpositioning 9.Applywoundgeldaily;packwith1rollofgauzeand coverwithDSD 10.Avoidmassagingaroundwoundsitesandoverbony prominences 11.Identifythephaseofwoundhealing(inflammation, proliferation,maturation) Evaluate 1.Patientwillregainintegrityofskinsurface

comfortable 6.Preventsskindamage 7.HavingHOBat<30degreesminimizesshearingof tissuescausedbyslidingdowninbed 8.Tomaintainalternativepositionsandpadbony prominences 9.Physiciansorder.Promoteshealingandprotects wound 10.Thiscanresultindeeptissuedamage 11.Accurateunderstandingoftissuestatusprovidesa basisfordeterminingappropriatetreatments.

31

PRIORITYDIAGNOSES RiskforInfectionr/topen wounds Subjective/Objectivedata: Elevatedtemp.,redness, warmth,edema,prurulent drainage,odor,abnormal labvalues,positivecultures Physicians specific med orders, including dose, route, and times

NURSINGINTERVENTIONS Assess 1.Temperatureqshiftandprn 2.Forredness,warmth,edema,exudates,odor,elevated temperature 3.Skinformoisture,texture,andturgor 4.Nutritionalstatus(weight,calories,protein,CHO,fats, vitamins,minerals) Prevent 1.Monitorlabvalues(WBC,differentials,prealbumin, serumalbumin,cultures) 2.Washandthoroughlydryskin(pat,dontrub).Take particularcarewithskinfolds 3.Encourageabalanceddiet.Emphasizeproteins,vitamins (A,B6,B12,C,E),folicacid,linoleicacid,zinc 4.Give1tabletmultivitaminPOdaily@0800 5.Givezincsulfate220mgPOdaily@0800 6.AdministerVancocin1GMIVq12hours@0600/1800and Unasyn1.5GMIVq6hours@0200/0800/1400/2000

RATIONALES 1.Elevatedtemperatureisasignofinfection 2.Theseareindicationsofinfection 3.Intactskinisnaturesfirstlineofdefenseagainst microorganismsenteringthebody 4.Optimizingnutritionalintakeisneededtopromote woundhealing 1.Labvaluesprovideaglobalviewofpatientsimmune function 2.Maintaingsuppleskinisbestmethodforkeepingskin intact 3.Thesenutrientsarerequiredforefficientfunctioningof theimmunesystem 4.Physiciansorder.Promoteshealing 5.Physiciansorder.Promoteshealing 6.Physiciansorder.Treatsinfection

 RiskforIneffectiveTissue Perfusion,peripheralr/t interruptedbloodflow secondarytoprolonged immobility Subjective/Objectivedata: Redness,warmth,edema, increaseincircumferenceof calforthigh,absentpedal pulses,cool/paleextremity

7.Takemeasurestopreventnosocomialinfections(frequent handwashing,steriledressingchanges,standard precautions) 8.Encouragefluidintake,ifnotcontraindicated Evaluate 1.Patientwillbecomefreeofinfection 2.PatientsWBCcountwillreturntonormalparameters Assess 1.Calvesandthighsforredness,warmth,edema,venous dilation;alsocoolness,pallor,edemadistaltoinflammation 2.Pedalpulses Ackley indicated both active and Prevent passive ROM only passive is 1.PerformpassiveROMexercises listed due to pts quadriplegia this makes the intervention 2.Encouragedeepbreathing specific to the pt 3.Measurecalvesandthighsdailywhilepatientissupine. Monitorforincreasedcircumference

7.Hospitalacquiredinfectionsincreasemorbidityand mortality 8.Fluidintakehelpsthinsecretionsandreplacefluidlost duringfever 1.TheseareindicatorsofDVT 2.Absentordiminishedpedalpulsesindicatearterial insufficiency 1.Toincreasecirculation,whichwillpromoteperipheral perfusion 2.Increasesnegativepressureinthelungsandthoraxto promoteemptyingoflargeveins,thusincreasing peripheralperfusion 3.ToassessforextremityenlargementcausedbyDVT. Anincreaseof>2cmin1dayissignificant,aswellascalf

 Powerlessnessr/tlossof function Subjective/Objectivedata: Crying,passivity, irritability,guilt, frustration,verbalizationof havingnocontrol

4.Consultphysicianaboutuseofantiembolismstockings 5.Increasefluidintaketoatleast23L/day,ifnot contraindicated 6.GiveLovenox40mgSCdaily Evaluate 1.Patientwillmaintainadequateperipheralperfusionas evidencedbynormalskincolor,temperature,andpositive bilateralpedalpulses Assess 1.Low:expressionsofuncertainty,passivity 2.Moderate:nonparticipationincareordecisionmaking whenopportunitiesareprovided;resentment,anger,and guilt;reluctancetoexpresstruefeelings;passivity; dependenceonothersthatmayresultinirritability;feeling alienationfromcaregivers;expressionsofdissatisfaction andfrustrationbecauseofinabilitytoperformprevious tasks/activities;expressionofdoubtregardingrole performance;doesnotmonitorprogress;doesnotdefend selfcarepracticeswhenchallenged;inabilitytoseek

diameter>3cmlargerthantheothercalf 4.CompressionstockingshelppreventDVTin hospitalizedpatients 5.Toreducehemoconcentration,whichcancontributeto developmentofDVT 6.Physiciansorder.PreventionofDVT Itisnecessarytodeterminethelevelofpowerlessness thepatientisexperiencingsothatthenursecanchoose appropriateinterventions. Thispatientexhibitsbehaviorsfromallthreelevels.

informationregardingcare 3.Severe:verbalexpressionofhavingnocontroloverself care,orinfluenceoversituation,orinfluenceover outcomes;apathy;depressionregardingphysical deteriorationthatoccursdespitepatientscompliancewith regimen 4.Assessmyownphilosophiesofcaretoensurethatcontrol issuesorlackoffaithinthepatientscapabilitieswillnot biasmyabilitytointervenesincerelyandeffectively Prevent 1.Bealertforbehaviorsthatattempttoassertpower,evenif theyseemconfrontational.Assistpatienttochannelthose behaviorsinaneffectivemanner 2.Determinethepatientslocusofcontrolrelatedtoher health 3.Establishatherapeuticrelationship(spendoneonone timewithher,keepcommitments,provideencouragement, listenattentively,beempathetic) 4.Allowpatienttoshareherfeelings 5.Encourageparticipationinselfcareandselfmanagement

4.Professionalselfreflectionisanimportantelementin themaintenanceofanempowermentphilosophy.Such reflectionhelpsthenursecometotermswiththe cognitivedissonanceoftryingtoempowerpatients withinorganizations(healthcaresystem)thatare inherentlydisempowering 1.Patientislookingforameasureofcontrol.Assisting hertochannelherenergiesappropriatelyis empowering. 2.Anexternallocusofcontrolcanleadapatientto believethatshehasnopoweroverasituation 3.Powerlessnessisheightenedwhenthereisasenseof distance,violation,ordisconnection 4.Listeningtothepatientreducesherfrustration 5.Themoreapatientparticipatesinherowncare,the

Note the specificity you would not place the phone, food, or drink within reach because this patient is unable to move. She is, however, able to grasp items and use her fingers

ofillness.Haveherassistinplanningcarewhenever possible 6.Keepitemsthepatientneeds,wants,andisabletouse withinreach(tissues,calllight,televisionremotepatient isabletouseherfingers) 7.Giverealisticandsincerepraiseforaccomplishments 8.Acknowledgesubjectiveconcernsorfears Evaluate 1.Patientwillstatefeelingsofpowerlessnessandother feelingsrelatedtopowerlessness 2.Patientwillparticipateinplanningandimplementing care,andmakedecisionsregardingcareandtreatment whenpossible 3.Patientwillverbalizehopeforthefuture

lesspowerlesstheyfeel 6.Wellbeingcanbeaffectedmuchmorebychoices relatedtoactivitiesofdailyliving.Patientisableto participateinherowncareifdevicesareaccessible 7.Givingrealisticpraiseassiststhepatientindeveloping positivefeelingsandenhancesselfconcept 8.Allfeelingsarepersonalandhavemeaningforthe patient

ChronicSorrowr/t permanentdisability Subjective/Objectivedata: Sadness,crying,fear, verbalizationof helplessness,hopelessness, lackofappetite

Assess 1.Forexpressionsofsadness,anger,beingmisunderstood, confusion,depression,disappointment,emptiness,fear, frustration,guilt,orselfblame,helplessness,hopelessness, loneliness,lowselfesteem,beingoverwhelmed Prevent 1.Identifyproblemswitheatingorsleeping 2.Spendtimewiththepatientanddevelopatrusting relationship 3.Helpthepatientunderstandthatsorrowmaybeongoing; notimetableexistsforgrieving,despitepopularthought Specify the patients loss 4.Evaluatepreviouscopingskills Does the pt have family, friends, government/social 5.Evaluatesupportsystems services?

1.Feelingssuchastheseareindicatorsofchronicsorrow 1.Bereavedindividualshaveamoderateriskforpoor nutrition 2.Anempatheticpersonwhotakesthetimetolisten, offersupportandreassurance,recognizesandfocuses onfeelings,andappreciatestheuniquenessofeach individualishelpfultopatientsexperiencingchronic sorrow 3.Studieshavedemonstratedthatfeelingsofsadness, anger,frustrationandfearoccurperiodicallythroughout thelivesofpeopleexperiencingchronicloss(this womanisgrievingherlossoffunctionandprevious lifestyle) 4.Helpsthenurseunderstandwhathashelpedthe patientinthepastanddeterminewhethernewcoping strategiesareneeded 5.Helpsthenursetounderstandwhetherthepatienthas supportorwhetheradditionalresourcesareneeded

6.Identifyavailablecommunityresources,includinggrief counselorsorsupportgroups 7.Identifywhetherpatientisexperiencingdepression, suicidalideation,orotheremotionaldisorders.Arrange forcounselingservicesasappropriate Evaluate 1.Patientwillexpressappropriatefeelingsofguilt,fear, anger,orsadness 2.Patientwillidentifyproblemsassociatedwithsorrow (changesinappetite,insomnia,nightmares,decreased energy) 3.Patientwillplanforthefutureonedayatatime

6.Supportgroupscanserveasahelpfulmeansto improveinterpersonalcopingstrategies 7.Counselingwiththerapeuticgoalsettinghasbeen showntobehelpful

38

WhySuchLongCarePlans?
Youarenotthefirststudenttoaskthatquestion.Muchgrumblingand complaininggoesoninregardtoBCCcareplans.Whileyoureuplateatnight allyoucanthinkisThisisridiculous,Theyexpecttoomuchinformation, Whysomanydetails?DoIreallyneedtoknowthis?andsoon,andsoon, andsoon.Welcometonursing,theBCCway! Iadmittoexperiencingawiderangeofnegativefeelingsaboutourcareplans; Iwentsofarastowonderiftheinstructorsprimaryreasonforrequiringthemto besodetailedandlengthywastotortureus!Imsureyouvehadoccasionto feelthesamewayandifyouhavent,youwill.Well,letmeassureyouthat thesefeelingsareborneoutofsheerfrustration(theyarentreallytryingto tortureyou).Imetmanynurses,fromseveraldifferentschoolswho,upon gettingalookatmycareplan,gleefullyinformedmethattheirswerenothing likethat.Oh,howIenviedthem!Now,notsomuch. Iamconvincedthatthesecareplansmademe(andwillmakeyou)abetter nurse.Likeyou,Ioftenbelievedthatsomuchofthedetailedminutiaethatwe wererequiredtolookupandunderstandwerewayaboveandbeyondwhatwe neededtoknow.Clottingfactors?Myjobistogivethewarfarinandmonitor prothrombintime;isntitthephysiciansjobtoworryaboutclottingfactors? Betablockers,calciumchannelblockers,ACEinhibitors?Theyallcontrolhigh bloodpressure,right?DoIreallyneedtoknowthedifferencesbetweenthem? Imtryingtobeanurse,notapharmacist.Detailssuchasthesedrovemeto heightsoffrustrationandresentmentthatsometimesmademequestionwhether allthisworkwasworthit.Then,gradually,astrangeandwonderfulthing begantohappen...Iknewwhatclottingfactorswereandwhichoneswere targetedbywhatmedications,withouthavingtolookitup.Withoutabook,I couldtellmypatientwhichclassofantihypertensiveheratenololwas,andhow thatparticularmedicationworkstolowerherbloodpressure.Inadvertently, almostwithoutmybeingawareofit,detailssuchasthesewereincorporatedinto myknowledgebasethroughthetediumofhavingtoresearchthemoverand overwhilewritingcareplans.Youwillresearchandwriteaboutsurgeries, medicalconditions,laboratoryvalues,andmedicationssomanytimesyouwill almostbeabletorecitetheminyoursleep.Asaresultofthis,youwill eventuallycometoaplacewhereyouareabletosynthesizeallthisinformation inyourheadandunderstandhowitalltiestogethertoaffectyourpatient.You arelearningtocriticallythink.Theexhaustivenumberofhoursyouspendon careplansare,minuteforminute,hoursofinvaluablelearning.Thoughyou 39

maybesittingathome,researchingandwriting,youareundoubtedlygrowing inyourclinicalpractice. LetmesaythatIdoubtyouwilleverenjoywritingacareplan.However,the processwillbecomelesschallengingandtimeconsumingasyouadvance throughnursingschool.Moreover,youwillfindyourselfontheclinicalunit caringforyourpatientswithouthavingtoconsultyourcareplaneveryfive minutes.Seeyourselfpracticingwithconfidence...thatiswhatyourcareplans arepreparingyoutodo. 40

*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*

Section Four: Self Evaluations

*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*

Afteryourclinicalweekisoveritwillbetimetoturnyourattentionto completingyourselfevaluation.Thisisawritingintensiveexercisethatrequires youtoreflectonyourclinicalexperienceandhonestlycritiqueyourperformance asaproviderofcare,managerofcare,andmemberoftheprofession.Itisan importantcomponentofyourlearningandatoolbywhichtomeasureyour growthasapractitioner.Yourinstructorwillknowhowwellyouaredoingand whatyourstrengthsandweaknessesarebyobservingyoueachweekasyou interactwithpatientsandstaffinclinical;shewantstoknowwhetheryouknow, andyourselfevaluationisthetoolsheusestodeterminethat. Aselfevaluation(orselfeval,asitiscommonlycalled)isneverrightor wrong.Youarenotgradedonit.However,itallowsyourclinicalinstructorto understandyourlevelofselfawareness,aswellasyourinsightandjudgment, whichwillbeconsideredasshepreparesyourendofcourseclinicalevaluation. Asnurses,itisimportantforustoperformselfassessmentssothatweareaware offeelingsandpotentialprejudicesthatmayaffectourpractice.Itis unacceptableforapatienttoreceivelessthanoptimumcarebecauseourbeliefs presentaconflictwhetheritbewiththeirpersonality,race,culture,religion, sexualorientation,orlifestyle.Examiningourownskills,attitudes,andfeelings issomethingweneedtodothroughoutthecourseofourcareers,sothatwecan beconfidentthatweareprovidingthebestcarewepossiblycan.Donotmake themistakeofthinkingthat,onceyouleavenursingschool,yourselfevaluation daysareover.Verymuchtothecontrary,theyarejustbeginning. Iencourageyoutoputyourbesteffortintopreparingthisdocument.Believe me,Iunderstand,andempathizewith,thetemptationtorushthroughandleave outimportantobservationsinanefforttojustgetitdone.Youretiredaftertwo daysofcareplanningandclinical(onlittlesleep,mostlikely)andthelastthing youfeellikedoingiswritingsomemore.Heck,youdontwanttothink anymore;youwanttocomehomeafterthatsecondday,lieonthecouch,and maybeindulgeinsomecomfortfood.Ifyourereallylucky,andthestarsareall linedupjustperfectly,anap!TrustmewhenItellyouthatthereisntanursing 41

studentalivewhohasntfeltthatway.Heresmyadvice:ifyouhavetheenergy andmotivation,thinkaboutandwriteyourselfevalrightaway,whilethedetails ofclinicalarefreshinyourmind.However,ifbeingtiredmightcauseyouto rushthroughit,donotwriteyourselfevalrightaway.Itsreallythatsimple.In yoursecondyear,yourselfevalisduethemorningafteryoursecondclinical day,withoutexception.Puttingitoffforafewhoursrestisnotdetrimental;you arestillcompletingitbeforeimportantdetailshaveachancetoslipaway.In yourfirstyear,however,youmayhaveafewdays,perhapseventheentire weekenddependingonyourclinicalinstructor,beforeitisdue.Thesamerule appliesastoafewhoursrest.Donot,however,putitoffformorethan24hours. Waitinglongerthanthatmaycauseyoutoforgetdetailsaboutwhatoccurredin clinical,nottomentionthatattemptingtowriteitatthelastminuteputsyou rightwhereyoudontwanttoberushingtogetitdone.Ifyouabsolutelymust putitoff,doyourselfafavorandatleastjotdownsomenotesforreference regardingclinicalthatyouwanttoinclude.Iknowitisdifficulttobelievebut youtrulycanforgetthings,ornotrecallthemasclearly,aslittleasonedayafter clinical.Youretired,yourestressed,yourereadingtextbooksandhandouts,in largevolumes,almostconstantly.Itisveryeasyforclinicaldetailstoget crowdedout. So,restabitifyouretired,butgetthatselfevaldoneassoonaspossible.

SampleSelfEvaluations
HereIhaveprovidedsamplesoffirstandsecondyearselfevaluations.They areintendedtoillustrateforyouthecomprehensivenessanddegreeofdetailthat isexpected.Youwillnoticethattheformatandcontentisabitdifferentforeach, buttheunderlyingconceptremainsthesameforboth:toevaluate,inwriting, yourclinicalskills. 42

BCC
SelfEvaluation NUR11&12 NursesRolesStudentComments
I.ProviderofCare a.DataCollectionIamfindingthatdatacollectionbecomeseasiereachweek.AsI growmorefamiliarwiththeKardex,medsheets,andthe organizationofthechartIamabletolocatetheinformationIneed morequicklyandefficiently. b.DataOrganizationIamstillstrugglingtofindawaytoorganizemynotesmore effectively.Mydataiswellorganizedonmycareplan,butitseems Iamspendingalotoftimesearchingthroughmynotestoaccessthe informationIwant,whichisdrawingoutthecareplanwriting process.Iamhopingthat,withpractice,Iwillbeabletobetter organizemynotetakingthinkingaheadtothetimewhen,asa RegisteredNurse,mynoteswillbewhatIwillactuallyworkfromas Icareforpatients. c.Planningselected approachesIplannedselectedapproachesaccordingtomyprioritydiagnosis, whichwasRiskforInfection.IunderstoodthatIwouldneedto observemypatientforanysignsofinfectionrelatedtohissurgical procedureandindwellingsuprapubicandFoleycatheters.In addition,Iplannedtocompleteathoroughskininspectionwhile providingAMcare.Theseapproacheswereconsistentwithmy identifieddiagnosis. d.ImplementingIimplementedcareasplanned,withtheexceptionofperformingAM

InstructorComments

Your instructor knows that you collected and organized your data she can see that on your care plan. Here, provide some explanation about how the process of collecting and organizing was for you.

Evaluate how and why you planned care as you did.

care.Thepatientwasscheduledtobedischarged,thereforebathand linenchangeweredeferredaccordingtohispreference.Ihadthe opportunitytoperformsomeskillsIhadntplannedforsuchas discontinuinghisIVandcatheter.Itwasalittledisconcerting,asa student,tobeputonthespotthiswaybutprovidedexcellent practiceinlearninghowtoadapttochangesinyourplanofcare. 1.Procedures (strengths&weaknesses)Ifeltmoreateaseperformingtheheadtotoephysicalassessment.I amgrowingmoreconfidentwiththisskilleachweekbutrealizethat thereisroomforimprovement.Wehavebeentaughttobeginour assessmentatthetopandworkourwaydown,butIfindthatImstill forgettingsomethingsalongtheway,thenhavingtogobackand lookatanareathatIvealreadypassed.Thegoodthingaboutthisis thatIamrememberingthatIforgotitinpreviousweeksI sometimesdidntrealizethisuntilfillingouttheflowsheet.This week,Irememberedwithoutneedingareminder. IthinkIdidwelldiscontinuingthepatientsIVandFoley.Withthe RNsguidance,Igatheredallthenecessarymaterialsforeach procedureandremovedtheIV,andthenthepenilecatheter.Itis quitedifferenttodothisonalivepersonthanitistodointhelab!So asnottomakemypatientnervousorapprehensive,IactedlikeId donethisahundredtimesbefore,whichwaschallenging,tosaythe least. Ihelpedthepatientdressandpreparefordischarge.Ispentalotof timetalkingwithhimthroughoutthecourseofmyshift.IfeelI displayedcompetenceinmostareastoday,notonlyincaringformy ownpatient,butinassistingmyclassmateswhenneeded.Inotice thatourabilitytoworkasateamseemstobeevolvingastheweeks progress.Weassistandconsultoneanotherwithconfidence,more secureinourclinicalknowledgebaseandpracticethanwewerejust

Were you able to implement care according to your plan? Why or why not? How did you feel about working your plan?

Describe and discuss any procedures you performed. Evaluate your accuracy and comfort level with honesty.

4or5weeksago. MybiggestweaknessismonitoringI&O.Iamnotasdiligentabout thisasIneedtobe.Imonitorandrecordtheoralintake,butI neglecttheintakefromIVfluid.Inthisclinical,Ididnotrecordany output.WhenID/CdthepatientsFoley,theRNtookthebagaway toemptyit.Iforgottoaskheraboutthevolume,andthenforgotto checkifithadbeenrecorded.Inordertoimprove,IthinkIllmake I&Oaprimaryfocusfornextweek. 2.PhysicalsafetyIwasawareofphysicalsafetyatalltimes,bothmyownandthatof mypatient. 3.BiologicalsafetyIworeglovesforallpatientcontact.Iwascarefultoavoidcross contaminationbychangingglovesbetweenD/CofthepatientsIV andD/CofhisFoley. 4.MedicationIfeltfineaboutresearching,retrieving,andadministeringmy Administration/patientsmeds.Hespoketomeaboutnotwantingtotakehisiron, Calculationbecauseitmadehimfeelsickandunabletoeat.Iconsideredhis wishesandspoketohisnurseaboutwithholdingit,andthendidso, indicatingsuchonhismedsheet. 5.OrganizationofcareIthoughtcarewaswellorganized.Althoughmypatientdidnot requireclosemonitoringoragreatdealofphysicalcareitwasabusy day.Mostofushelpedaclassmatecarefortheirpatientinsomeway whenwewerentcaringforourown. 6.ObservationsThemostimportantobservationImadetodaywashowwellwe workedasateam.Inretrospect,Irealizedthatweeachwereconfident aboutandfocusedonourindividualtasksbutfoundthetimetoask forandgiveassistancewhenneeded.Incomparisontoourearlier

Be willing to admit to weaknesses and mistakes. When you identify a problem area, discuss what you will do in an attempt to improve

Consider your positioning. Did you protect your back? Was the patients bed in its lowest position with the side rails up? Did you practice standard, contact, and airborne precautions when necessary?

Did you feel you were organized? Did you find yourself running around and rushing to get things done? What could you have done differently?

weeks,goneisthehesitation,fear,anduncertaintyaboutwhatis requiredofusandhowwearetoproceedwithpatientcare.Post conferencealsoreflectshowwevelearnedandgrown,asweare eachabletoprovideacomprehensiveyetsuccinctsummaryofour patientsconditionsandthedaysevents. 7.Communicationskills/IPR ChartingWiththeexceptionofI&O,aspreviouslymentioned,Ifeelfairly confidentwhencharting.Imsurethereisroomforimprovement, whichwillcomewithpracticeandrepetition.Untilthen,Ijustask beforechartingifIamuncertainaboutsomething. ReportingThisisgrowingeasierastheweeksgobyaswell.Iamgettingto knowthenursesontheunit,andviceversa,andamdevelopinga routineforconsultingwiththeRNpriortocare,andproviding updatesthroughouttheshiftasnecessary.Theyaregoodabout providinguswithinformationaswell,particularlyaboutprocedures wemaywanttotakepartin. TeachingItaughtmypatienthow,beforestanding,heneedstosituponthe edgeofhisbedforafewminutesinordertoavoidbecomingdizzyor lightheaded.Iprovidedanexplanation,andthenhadhim demonstrate. EvaluatingIwasabletoevaluatemypatientsunderstandingbyobservinghis abilitytofollowmydirections.Hewassuccessfulatassimilating knowledgeregardingthecontentofmyteaching. II.ManagerofCare Seeksassistancefrom appropriatehealthmembersAtthispointinclinical,Iamseekingoutmyclinicalinstructoror

Include observations about anything you found interesting or were able to learn from

Was your charting clear, accurate, and comprehensive while remaining concise? How did you feel about charting? How might you improve?

Did you feel comfortable about differentiating between what you need/dont need to report? Was your nurse receptive? Cooperative?

primarynurseforassistancewhenneededandhavenotprogressed toconsultingmembersofotherdisciplines. III.MemberofProfession a.AgencyResourceManualsAlthoughIknowtheirlocation,Ididnotneedtoconsultresource manualsthisweek b.AgencyPolicies& ProceduresIwasawareoftheprocedurestofollowforcarethatIprovided.I understandthatIneedtoconsultwiththepolicyandprocedure bindersifatalluncertainaboutthehospitalsprotocols. c.SelfEvaluationIbelievemyselfevaluationtobehonest,comprehensiveand specifictothisweeksexperience. IV.ProgramRequirements a.AttendancePerfectattendancetodate b.AssignmentsAllassignmentscompleteandsubmittedontime c.MathExamPassedonfirstattemptwith95% d.Participationinpre andpostconferenceIbelievemyparticipationissatisfactoryandthatIampreparedto discussandshareanyinformationpertainingtomypatient assignment e.AppearanceIaminuniform,whichiscleanandpressed,asrequired. f.BehaviorAppropriateandconsistent. g.VeracityBeyondreproach,asisexpected

As a member of the profession, do you feel you are literate in the community of nursing? Do you understand how to find and utilize resources, such as policy, procedure, and protocol manuals? Do you feel that any knowledge you obtained from the manuals helped you grow as a member of the nursing profession?

Evaluate your self-evaluation

NUR51&52SELFEVALUATIONNAME:DATE:
Pleaseaddressthefollowingareasplusanyothersyouwishorneedtocommenton.UseEnd OfCourseBehaviorsasguide.AddpaperPRN.

PROVIDER(datacollection,NCP,worksheet,organization,
assessment,skills,revisions)

COMMENTS

Iammostlysatisfiedwithmyperformanceintheseareasthisweek.I wasabletogatherallpertinentinformationonmypatientand organizeiteffectively.IreallyfeltlikeIunderstoodthispatient,what herneedswere,andwhatIneededtodotocareforher.Ifeltreally comfortableaboutreprioritizingafterinteractingwithherthefirst day.Thishasbeenoneofmybestclinicalweeksasfarasmygrowth anddevelopmentasanurse.IfeltlikeIwasabletotakeinand synthesizenewinformationbasedonmyassessmentswithouthaving todiginabooktoknowwhattodo.Mycareplan(finally!)feltmore likeausefultoolratherthanaburden.Ibelieveitwasdetailedand thorough,andmyrevisionsappropriate,andprovidedmewitha usefulframeworkfromwhichtoprovidecare.Iambecomingless attachedtomyworksheet,aswell.AlthoughItakeitoutoccasionally, forremindersortojotdownnewinformation,Iamlessdependenton it.Iamawareofcognitivegrowthtakingplace,asIamabletokeep informationaboutmypatientinmyhead,aswellasassimilatenew findings,andanalyzehowthingsalltietogether. Myassessmentsarecarefulandthorough.Asastudent,Iamalways afraidofthepossibilityofmissingsomething(andprobablywill continuetobeasanurse).Forexample,Iworriedafterthefirst clinicaldaythatIhadnotbeenabletolookatmypatientsIVaccess siteduetothebandagingthatcoveredit.Byday2,whenIcouldsee thatthebandagehadnotbeenchanged,Igrewveryconcernedabout thefactthatnoonehadlookedatheraccesssiteforatleast24hours. Afterfirstgettingpermission,Iremovedthebandagingandwasable toinspecttheareaanddeterminethatthesitewasnormalandtheIV patent,muchtomyrelief.Myphilosophyisthatyoucanneverbetoo careful. Astoskills,Iwasabletolearnanddosomenewthingssuchas hanginganIVbagandsettingthepumpandremovinganNGtube.I wasdefinitelynervous,buttriedmybesttohidethatfromthepatient. Ineedmorepracticeandimprovementwiththeseskills,naturally,but nowthatIvedonethematleastoncetheyarenotsointimidating.

How was data collection? Did you encounter any difficulties? How do you feel about your care plan? Did you struggle with it and, if so, how and why? How did you feel about working from your worksheet? Do you prefer working directly from your care plan?

Be specific about assessments or skills that you are discussing

COMMUNICATOR(clarity,accuracy,useoftherapeuticinteractive
techniqueswithpts.,staff,charting)

IbelieveIamaneffectivecommunicator.Ilovetalkingwithmy

patientsandthusfarhavenothaddifficultyestablishingtrusting relationshipswiththem.Ialwayslistencarefullytowhattheytellme andtrytoadjustmytherapeuticinteractivetechniquestotheir individualneeds. Communicationwithstaffwasclear,beneficial,andbidirectional.I learnedsomethingsaboutclarityandaccuracyontheflowsheetwith thehelpofmyprimarynurse.Shetaughtmehowtochart procedures/treatments(likediscontinuingtheNGtube)andhowto putanasteriskbythenotationontheflowsheettoindicatethatIhad writtenanursingnoteaboutit.

TEACHER(assessneed,provideexplanationanddemo)
Italkedwithmypatientabouttheimportanceofturningand repositioningfrequentlyinordertopreventinfectionandskin breakdown.AlthoughIassuredherthatIwouldcheckonheroften (becauseofherdiarrhea),Itoldherthatitwasimportantforhertouse thecallbuttonifshemovedherbowelswhileIwasntthere,sothat herskinwouldnotbecomeirritated.Ialsodemonstratedcoughing anddeepbreathing,butwasmetwithconsiderableresistance,whichI feelwasduetoherinabilitytofocussecondarytohernauseaand discomfort.
You are always a teacher! Dont ever leave this blank or say that you didnt teach anything. Even if the patient wasnt receptive, describe what, and how, you attempted to teach

MANAGER(prioritizingfor2clients,delegating,interactingwithhealth
teammembers)

Ihadonlyaonepatientassignmentthisweek,andsodidnotneedto prioritize,nordidIdelegateanycare.Ididapproachmyprimary nurseaboutthepossibility/feasibilityofgettingthepatientoutofbed andwecollaboratedaboutinitiatingaPTconsult.Ultimately,we discoveredthattheMDhadalreadyorderedaPTevaluation. Nonetheless,Imgratifiedthatwewerethinkingalongthesamelines, andhadadiscussionabouthowtobestapproachthisaspectofthe patientscare.

Even if you do not have more than one patient, discuss how you managed care on your own, or with other health team members

MEMBER(legalethicalpractice;IDownstrengths/areastodevelop;seek learningopportunities)
Ibelievemyselftobeaconscientiousproviderofcare,respectfulof, andincompliancewithlegalandethicalguidelines.Mystrengththis weekwasmyabilitytosoothemypatientandcommunicate unconditionalpositiveregard.Shewasdistressed(andlikely embarrassed)aboutherexcessivediarrhea.Iwasabletohelpher relaxandassuredherthatitwasokayifshemadeamess,thatIwould berighttheretokeephercleanandcomfortable.Infact,Iencouraged hertojustletitcomeandnottrytoholditback(notthatshecould).

Try to be specific about what your strengths and weaknesses were this particular clinical week. As a member of the profession, do you feel you are improving in your own practice and/or improving nursing as a whole?

Thismaynotseemlikeabigdealtoanordinary(nonnursing)person, butasIleanedoverher,heldherhand,andlookedintohereyesasI spoke,Icouldseeherreliefasheranxietymeltedaway. Ineedtoworkonconsolidatingmycare.Itendtopacemyselfsothat Idontendupbeingboredandfeelinguseless.Ireallyneedto developinthisareabecauseIunderstandthat,asanursewithseveral patients,Iwillnothavetheluxuryofdoingthis.IamconfidentthatI willgetplentyofpracticeasmypatientassignmentgrowswiththe progressionofthesemester. Iamalwayseagertoobserveorparticipateinnewlearning opportunities.ThisweekIgottowatchoneofmyclassmatesuse steriletechniqueandchangeacomplicateddressing.

PROGRAMREQUIREMENTS(punctuality,prepandparticipationin
conference)

Ibelievemyperformanceintheseareaswassatisfactory.Ifeelthat preconferenceprovidedanexcellentfoundationbeforemeetingthe patient,andpostwasavaluableforumforevaluationofthedays objectives.

50

AFTERWORD
Itismysincerehopethatthismanualwashelpfulinguidingyouthroughthe careplanningandselfevaluationprocess.Itisimportantthatyouknowthat thesewritingendeavorsareonlythebeginningofwhatwillberequiredofyouin thenursingprogram.Thewritingassignmentswillgrowmorecomplexasyou progressthrougheachsemester,requiringahigherlevelofthinking, organization,andexpression.Learning,earlyon,howtowriteeffectivelywill provideasolidfoundationforthechallengestocome. Iencourageyoutotakeadvantageoftheservicesprovidedthroughthecolleges WritingLab.Theirexcellentstaff,comprisedoffacultymembersandpeertutors, canhelpyounavigateyourwaythroughanyphaseofthewritingprocess.In addition,youwillfindwritingsamples,specifictothenursingprogram,thatyou mayuseasmodelstoassistyouinsuccessfullycompletingyourownwriting assignments. If,afterreadingthismanual,youbelievethatIamaneffectivewriterand successfulstudent,thenIthankyou.However,Iaskyoutorememberthatmuch ofmysuccesswouldnothavebeenpossiblewithoutsomehelpalongtheway.I havenotonlyhadtheprivilegeofworkingastutor,buthavehadthebenefitof beingtutoredaswell,andthathasmadeallthedifference.Therehavebeen tutorsatthiscollegewhohelpedturnwhatwassimplygoodworkintomybest work.Iencourageyoutotakefulladvantageofthiscollegesmanyresources particularlytutoringandwatchyourselfgrow,andbecomethemostsuccessful studentyoucanbe. 51

References Ackley,B.J.,&Ladwig,G.B.(2006).Nursingdiagnosishandbook:Aguideto planningcare.St.Louis:MosbyElsevier. Carpenito,L.J.(2006).Nursingdiagnosis:Applicationtoclinicalpractice. Philadelphia:Lippincott,Williams&Wilkins. Fischbach,F.(2004).Amanualoflaboratoryanddiagnostictests.Philadelphia: Lippincott,Williams&Wilkins. Mosbysmedical,nursing,&alliedhealthdictionary(6thed.).(2002).St.Louis: MosbyElsevier. Potter,P.A.,&Perry,A.G.(2005).Fundamentalsofnursing(6thed.).St.Louis: MosbyElsevier. Springhousenursesdrugguide.(2006).Philadelphia:Lippincott,Williams& Wilkins. 52

AppendixA BasicHumanNeedsandRelatedNursingDiagnoses 1.Oxygenation Ineffectiveairwayclearance Impairedgasexchange Ineffectivebreathingpattern Ineffectivetissueperfusion(specifyperipheral,cardiopulmonary,GI,renal,or cerebral) Decreasedcardiacoutput 2.Hydration Deficientfluidvolume Fluidvolumeexcess Riskforimbalancedfluidvolume 3.Nutrition Impairedswallowing Selfcaredeficit,feeding Imbalancednutrition(specifylessthanormorethanbodyrequirements) Impairedoralmucousmembranes Nausea 4.InvoluntaryRegulation Delayedgrowthanddevelopment Hyperthermia Hypothermia Ineffectivethermoregulation Adultfailuretothrive 5.Elimination Impairedurinaryelimination Urinaryincontinence(specifyfunctional,reflex,stress,total,orurge) Urinaryretention Constipation Diarrhea Bowelincontinence Selfcaredeficit,toileting

6.Safety/Security Impairedtissueintegrity Impairedskinintegrity Riskforimpairedskinintegrity Riskforinfection Ineffectiveprotection Riskforfalls Riskforinjury 7.Comfort Acutepain Chronicpain Fear Anxiety Chronicsorrow Disturbedsleeppattern Ineffectivecoping 8.Activity Activityintolerance Impairedtransferability Impairedphysicalmobility Impairedbedmobility Deficientdiversionalactivity 9.Communication Impairedverbalcommunication Readinessforenhancedcommunication 10.Sensation Disturbedsensoryperception(specifyvisual,auditory,kinesthetic,gustatory, tactile,olfactory) Acuteconfusion Chronicconfusion 11.Selfesteem Disturbedbodyimage Ineffectivecoping Disabledfamilycoping Hopelessness

Powerlessness Noncompliance Situationallowselfesteem Chroniclowselfesteem Deficientknowledge Sexualdysfunction Socialisolation 12.Independence Ineffectivehealthmaintenance Deficientknowledge Healthseekingbehaviors 13.Hygiene Selfcaredeficit,bathing/hygiene Selfcaredeficit,dressing/grooming Impairedskinintegrity Impairedoralmucousmembranes