2. You too can survive nursing
school!!!!!!!!!!!!!!!!!"http://www.youtube.com/embed/PgvVTXhHz58
3. What is a care plan Why do nurse write care plans What are
the different parts of a care plan What other paper work will I
need to know How am I evaluated When is everything due
4. Provide a direction for individualized patient care. Provide
continuity of care for the patient with all hospital departments.
Provide documentation on patient and family needs.
5. Provides acuity for staffing needs. Provides reimbursement
for insurance which was started by Medicare and Medicaid and now
used by all insurance companies. This is how hospitals and patients
receive payment. http://youtu.be/Ll3uipTO-4A
6. ActualWhat is actually wrong with the patient. Psychosocial-
Nursing Process and SelfConceptRelated NANDA Nursing Diagnoses
Ineffective Role Performance Body Image Disturbance Chronic low
selfesteem Selfesteem disturbance Situational low selfesteem
Personal Identity disturbance
7. Related NANDA Nursing Diagnoses Ineffective Role Performance
Body Image Disturbance Chronic low selfesteem Selfesteem
disturbance Situational low selfesteem Personal Identity
disturbance
8. What is your patient at risk for based on their nursing
diagnosis. Nursing diagnoses that are in the "risk for" categories
may not need the AEB portion of the statement, since there is no
actual evidence. However, you should avoid using too many "risk
for" diagnosis. One or two, out of eight to ten, is acceptable.
http://www.atrane.org Link to site
9. Nursing diagnosis Goals for patient and family Nursing care
Nursing scientific rational Evaluation
10. Begin with a complete assessment of your patient. Get as
much information as possible from the chart, such as lab data,
x-ray reports, physician history and physical exam
11. Subjective-This is what your patient tells you. My head
hurts States on scale of 1-10 Myhead hurts at 8.Objective- This is
what you see.Patient rubbing head.
12. This helps you decide what is really wrong with your
patient. You must listen to know what they are not telling
you.
13. BMPNa L124 136-145 mEq/LK H5.8 3.5-5.1 mEq/LCO2 25 23-29
mEq/LCl 101 98-107 mEq/LGlucose H107 74-100 mg/dLCa 10.1 8.6-10.2
mg/dLBUN 17 8-23 mg/dLCreatinine 0.9 0.8-1.3 mg/dLKey: L=Abnormal
Low, H=Abnormal High, WNL=Within Normal Limits,
*=criticalvalue--------------------------------------------------------------------------------Specimen(s)
Collected: 2/10/08 14:30 Lab Accn No. 223457Specimen: Blood Date
Reported: 2/10/08 15:30Test Name Patients Results Ref. Range
UnitsHGB L7.0* 14.0-18.0 gm/dLHCT L21.1 42.0-52.0 %Comment: Hgb of
7.0 and Hct of 21.1 reported to Dr. J Smith at 15:15 on 2/10/08 by
J.DoeDate Reported: 2/10/08 18:40HGB A1c
14. It is not a medical diagnosis A nursing diagnosis is the
plan of care for your patient which all member of the staff will
follow as they care for the patient.
15. The nursing diagnosis From NANDA-1 list Related To (R/T)-
what is causing the nursing diagnosis. Defining Characteristics-
AEB ( as evidenced by) signs and symptoms better known as
subjective and objective data
16. A goal is what you want your patient to achieve. I has to
be measureable with a time frame noted. An example is: You will
graduate in 3 Semesters
17. Must be : Patient centered Clear and concise Observable and
measurable time limited Realistic one behavior /goal determined by
patient, family, nurse together.
18. MEASURABLE NON -MEASURABLE Identify Describe Perform Know
Relate State Understand List Verbalize Appreciate Demonstrate Share
Think Express Communicate Accept Exercise Cough Feel Walk Stand Sit
Discuss Has an increase in Has a decrease in Has an absence of
19. What are you going to do to help your patient reach their
goal. This is what you do daily for your patient. If you give your
paper to a peer would they be able to follow your intervention or
plan of care.http://www.youtube.com/watch?v=xRFIDg9BPnQExample: If
you study hard then you willgraduate
20. This is the scientific reason you did this for your
patient. You must tell us (cite) where you got your information.
This could be your from your books or a reliable internet source. I
studied and went to class. I sat on the front row and took
notes.
21. Poor Procrastination OnAttendance Assignments Failing To
Take NotesNegative orthoughts Following teacher instructions Poor
time management
22. Did your patient reach their goal in the time frame that
you allowed for them Did your patient not reach their goal and do
you need to extend the timeframe or is this an unreachable goal and
you need to start over? Student passed in 3 semesters and met goals
Student did not pass in 3 semesters and goal not met.
23. EYEBALL SHEET
24. We have covered every aspect of this paper
25. This is the form you will turn in daily and it will help
you write your care plan
26. This form will be given to you on Friday after clinical. If
your instructor is very busy, you will receive it on Monday.
28. Nursing Diagnosis using subjective and objective Data
Nursing rational andevidence E valuation met Or not
29. What is a care plan? What is a nursing diagnosis What is a
rational What is an evaluations What is an intervention How long is
an intervention How long is a goal
30. NURSING CARE
PLANSSTUDENT____________________________________PATIENT
INITIALS____________ROOM NUMBER__________DATES________________
ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
(supportive data) (patients need) (nursing care needed)
(documentation of care) (status of goal)FACTUAL DATA PROBLEM
STATEMENT NURSING PLAN FOR PROBLEM DOCUMENTATION STATUS OF THE
GOALSupports your problem. This This is the name you give the Ask
yourself, What can I do for Ask, What will I document? Ask
yourself, Did Iinformation has to be problem. Ask yourself, the
problem? Any information that pertains to accomplish my
goal?current, or perhaps past What is the problem? the problem. 1.
Look at your goal & askhistory and NOT make You can use the
NANDA list These are not to be numbered. yourself a question
relatedbelieve. Think of it as of problem statements OR if This is
your actual narrative to it - whether your Goal charting notes just
like on your was met completely, metsupportive data that proves
none apply, make a problem Think about the following: Assessment
Sheet in Level 1 or partially, or not met at all.you have an actual
or statement using one of the Observations you make related to
Write this down.potential problem. It must words: this problem,
(include assess- charted observations in the nurses notes in the
chart. NOTE: This is 2. Answer the question in ahave at least 2
pieces of Alteration Impaired ment of the pt re: to the body
Summarized Evaluation NOT a restatement of your plan in
theinformation to support Deficit Ineffective system re: this
problem, diag- past tense! Also it DOES NOT have to Statement and
relate it toproblem. Dysfunction Intolerance nostic tests, and
reporting of address each part of the plan. DO the M easurable Part
of the Excess findings to charge nurse. (Use NOT number this
section or leave Goal. Write this down.Ask yourself, Why do I your
senses). spaces. Also any conclusions, or 3. Does the problem
orthink this is a problem? Refrain from using: Tasks you can do
(things you can judgments that are improper in potential for the
problem Decreased Cardiac Output* do to prevent, repair, or reduce
still exist? Write this down. Disuse Syndrome charting are not
proper here.Think about your pts: the problem). This includes
Students have best results in 4. Then, state if you will Impaired
Gas Exchange* Continue with your plan -1. Medical Diagnoses
Impaired Physical Mobility medication adm., oxygen, learning how to
word this section dressing changes, turning, either as stated or as
S & S from Dx that your Decreased Mobility (of any kind) when
they do not even look at the enema, catheter insertion, revised or
Discontinue Plan. pt is having right now Risk for Infection**
planning section. Write this down. If no S&S right now, just
Risk herapeutic Regimen* T of Ineffective Management of nutrition,
fluids, etc. NOTE: You must have list the Dx as support Teaching of
patient & family Document: Date/Time something to back up this
*T hese problems must have specific (includes not only what the 1.
Observations you made evaluation in your2. Medication List data,
measurements, lab tests, etc. in doctor orders but what you as 2.
Reporting observations and documentation in the Side effects? order
to use these problems. the nurse will teach the changes in
condition to Implementation column patient. Also should include
appropriate personnel (Implementation supports or **T here may be
some very specific proves your evaluation3. Abnormal Lab? cases
where it may be applicable. how you will determine the 3. Care
given to the patient patients understanding of the statement). T
hink, what can an infection can 4. Response of the pt to the care
cause? Use that as a problem instead. teaching.) 5. Results of your
actions, Examaple: diagnostic tests, medications Goal was partially
met. The Goal: What do you plan to Be very SPECIFIC and very
administered, etc. patient washed his face but did not accomplish?
Must be pt - THOROUGH. Include details like 6. Teaching specific to
patient brush his teeth himself. The centered, AND specific, how
much, frequency (how often), problem still exists. Continue meds,
needs, problems, with the plan as revised. measurable, attainable,
etc. preventative care. realistic, & time-sequenced. DATE
REVISIONS OR ADDITIONS EVERY DAY! DATE ENTRY EVERY DAY!
31. Mr. Goodpatient is a 60 year old male admitted with a
diagnosis of acute myocardial infarction.This is the data collected
during the assessment.Subjective: Mr. G. is complaining of
severecrushing chest pain unrelieved by rest whichhas lasted for 2
hours. The pain is substernaland does not radiate. He states the
pain is a 9on 0-10 pain scale. He says he smokes 2 packsof
cigarettes per day, is a manager at anelectronics firm, and that
his father died @age59 of a heart attack
32. Objective Data: Vital signs: Pulse 110 and irregular BP
90/68 Resp. 28 His cardiac monitor shows sinus tachycardia with
frequent PVCs His heart sounds are normal except for the
irregularity and his lungs are clear. He is pale, diaphoretic, and
holding his chest.
35. DeWitt, S. (9th ed), Medical- Surgical Nursing Concepts and
Practice, St. Louis, Mo., Saunders
PowerPoints.http://emievil.hubpages.com/hub/7-Bad-Study-Habits-A-College-Student-Must-Not-HaveMicrosoft
clip art and microsoft officeCase studies from previous classes and
patientfiles.