Care Plan Rules of the Road

Jill Barry RN, MSN, CPNP-PC, ARNP Nancy ONeill RN, MSN, CNM

Why the torture??

Remember that the ultimate purpose of the care plan is to guide all who are involved in the care of this person to provide the appropriate treatment in order to ensure the optimal outcome during his/her stay in our healthcare setting. A caregiver unfamiliar with the patient/resident should be able to find all the information needed to care for this person in the care plan (Sox, 2010).

Nursing Process
Assessment Diagnosis Planning Implementation Evaluation

Assessment

Assessment
Primary source of data. Helps compile a list of problems to formulate nursing diagnoses. 2 parts
Subjective Objective

Data
Subjective
What the patient, family member, or caregiver says about the situation.

Objective
Information from your senses, lab work, diagnostic testing, and chart review.

Data
Do not cut/paste your data. This is not cookie cutter data. Only include the data that is pertinent to that nursing diagnosis.

Diagnosis

Actual Diagnosis
4 parts
Label Definition Defining Characteristics Related Factors

Risk for Diagnosis

4 parts
Label Definition Risk Factors Related Factors

Diagnostic Statements
1 part
Wellness diagnosis
Readiness for enhanced hope

Syndrome nursing diagnosis

Impaired environmental interpretation

syndrome

Diagnostic Statements
2 part
Risk nursing diagnosis
Risk for infection related to open

abdominal wound

Possible nursing diagnosis

Possible feeding self-care deficit

related to fatigue and IV in right hand (Carpenito, 2002, p. 11)

Diagnostic Statements
3 part
Actual diagnosis
Impaired skin integrity related to

prolonged immobility secondary to fractured pelvis, aeb 2 cm sacral lesion (Carpenito, 2002, p. 15)

Diagnostic Statements
Common Errors
Use of a medical diagnosis Use of situations
Pregnancy
Alteration in nutrition: Less than body requirements r/t vomiting secondary to pregnancy aeb weight loss of 5 pounds in second trimester.

Pneumonia instead of Ineffective airway clearance

Use of diagnostic studies

Cardiac catheterization

Fluid volume deficit r/t hemorrhage secondary to traumatic cardiac cathereterization aeb baseball size hematoma on right thigh

Diagnostic Statements
Common Errors
Use of medication side effects
Alteration in comfort related to pruitis secondary to Morphine administration.

Use of treatment or equipment

NG tube or tube feeding

Planning

Goal
Can be positive or negative
Must be patient centered
Patient will Patient will maintain/gain Patient will not experience/will not complain of..

Must have an adequate time frame (be attainable)

Must be specific Must be measurable Use AEB

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

Patient will show no signs and symptoms of infection aeb temp <101.5, no purulent drainage from woundby time of discharge.

Implementation

Interventions
Should be specific for your patient, not your diagnosis
Teaching an adult to use an incentive spirometer Q1 while awake may be appropriate, but for a child you would state to blow bubbles Q1 while awake. Use nursing based, peer reviewed sources when providing rationale for your interventions. You must use a nursing journal article to support at least 1 intervention. You may use your careplan book and/or textbook for some interventions.

Evaluation

Evaluation
2 parts
Evaluation of each intervention
This is your data for each intervention
Intervention: Assess patients vital signs every shift Evaluation: Patients vital signs at 1400 were BP 96/43, temp 98.9, HR 120, RR 36.

Evaluation statement for each nursing diagnosis

This is your evaluation of the goal
Goal: Patient will gain a minimum of 30 grams per day through discharge. Evaluation: Goal met. Patient gained 35 grams 11/9/10, 45 grams 11/10/10, and 40 grams 11/11/10. Patient discharged home 11/10/10.

References
Carpenito, L. (2002). Nursing
Lippincott.

diagnosis: Application to clinical practice. (9th ed.). Philadelphia:

Sox, H. (2010). What is a careplan? Retrieved from www.careplans.com/pages/about