CAREPLAN WORKSHOP

CLUSTER DATA DRY MUCOUS MEMBRANES CONCENTRATED URINE REDNESS ON SACRUM FOLEY CATH NO BM FOR 4 DAYS SOB ON EXERTION UNSTEADY GAIT ABDOMINAL PAIN

DIAGNOSIS MUST USE NURSING DIAGNOSIS FORMAT 3 PARTS FOR ACTUAL PROBLEM 2 PARTS FOR HIGH RISK PROBLEM

ACTUAL FLUID VOLUME DEFICIT R/T INSUFFICIENT INTAKE AMB DRY MUCOUS MEMBRANES AND CONCENTRATED URINE

HIGH RISK RISK FOR INJURY R/T UNSTEADY GAIT

LIST ALL DIAGNOSES AND THEN DO CORRECT FORMAT ON 10 MOST IMPORTANT (HIGHEST PRIORITY) PROBLEMS

Then choose 2 top problems (highest priority) You will need a separate careplan page for each

problem sheets Start out writing out your problem (remember it will be in nursing diagnosis format) Then you’ll write S (subjective data) and O (objective data). These are your supporting data

Example: High risk for infection r/t tube in bladder S: Denies pain O: clear urine, temp 98.7 Altered tissue integrity r/t immobility S: My bottom feels scratchy O: 2.3x3.2 decub on sacrum. Stage 2.

Patho- How does the r/t cause the problem? How does being immobile lead to skin breakdown. How can having a catheter lead to infection?

GOALS Short term goal If possible want to see by end of your shift. Needs to be within a week. Be specific in your time element. Also be specific in your outcome criteria. Needs to be patient centered. Pt will name 3 foods high in potassium by end of my shift. Pt will lose 1 pound by 3/15/16.

Long term goal By discharge is usually a good long term goal. Or you may use 1 week or longer. Pt will have no redness at IV site by discharge. Pt’s temp will remain <99.6 by 3/15/16.

INTERVENTIONS Interventions must by nurse centered. “Nurse will-” Interventions have to be specific, such as: Nurse will turn patient every two hours on the even hours around the clock. Nurse will weigh patient every am at 7:30 a.m. with the same scales wearing only a hospital gown.

All interventions must be specific and directed toward either measuring your outcome criteria or working toward your outcome criteria. You must have an assessment intervention for each outcome criteria. Example: If you say that your patient’s temp will be <99.6, then you should assess temp (and make sure you are specific about this). Nurse will assess temp q 4 hours 8-12-4-etc.

You must also have at least 4 action interventions for each problem You must also have at least 4 action interventions for each problem. Action interventions are things you do to either maintain patient’s status, or improve their status. Example: Nurse will encourage patient to drink 100 ml. fluid each hour from 8 a.m. until 6 p.m.

Each intervention has to have a rationale and a source for that rationale. Interventions and Rationales should not all come from same source. A rationale is why are you doing this intervention. How will it help?

Evaluation Evaluate your interventions—in other words, how did the patient react when you performed the intervention? Did it help? Do you need to make any changes in the plan of care? Do you need to do something more often? Do you need to stop doing an intervention? Evaluate your goal. Was it met? If not, or if time not adequate, what was progress toward goal?