Don’t copy these guys! They are plans I used in school and certainly haven’t been review by a group of peers or experts. Use as an example to do your own or to get ideas from:
See Tired Studen Nurse webblog for much more and better care plans: http://danibanani.wordpress.com/
| Patient: SC | ||
| Nursing Diagnosis: Acute Pain r/t recent surgical procedure as evidenced by patient’s agitation, patient stating pain at 3 on a 0-10 pain scale, patient constantly clearing throat, and patient stating her throat was sore and dry. | ||
| Goals | Interventions | Evaluation |
| Short-term goal: Patient will have pain at less than a 3 within thirty minutes. | 1. Administer morphine 2mg/ml, IV push, as prescribed, immediately (10:15). | Goal met: Patient stated that pain was at a 2 on a 0-10 pain scale at 10:45. |
| 2. Provide patient with pillows in chair for proper alignment and quiet atmosphere to allow for pain medication to take effect after administering medication. | Goal met: Patient resting quietly, properly aligned within 10 minutes of pain medication. | |
| 3. Have patient suck on hard candy to relieve hoarseness and dry throat. | Goal met: Patient used hard candy and reported relief of dryness and some improvement of hoarseness. | |
| Long-term goal: Patient will maintain a pain level of 3 or less during remaining of hospital stay. | 1. Instruct patient to request pain medication as needed and before pain is at level 3 on a 0-10 pain scale. | Goal met: Patient stated understanding that she should ask for pain medication as described. |
| 2. Assess pain level every 2 hours and administer pain medication as needed. | Goal not met: Continue intervention. | |
| 3. Remind patient of hard candy or lozenges and voice rest should be practice for relief of throat dryness and hoarseness. Also provide humidification if problem persists. | Goal partially met: Patient reminded of intervention. Documentation of problem should help nurses on succeeding shifts to continue or change intervention as needed. | |
Problem List (List problems as you observe them, then rank according to highest priority)
| Rank | Problem | |||||
| 1 | Impaired Skin Integrity | |||||
| 2 | Knowledge deficit – going home with Foley catheter | |||||
| 3 | Disturbed Body Image – having to wear a Foley for 2 weeks | |||||
| Develop a care plan based on the top two problems above.Nursing Diagnosis – Use PES format – (Based on the objective and subjective data from your worksheet) | ||||||
| Nursing Diagnosis (Problem) r/t Etiology (What caused the problem) AEB Symptoms (Evidence of the problem)Impaired Skin Integrity r/t surgical removal of prostate AEB three derma bonded incision sites and one right midline immediately post JP drain. | ||||||
| Expected Outcomes | Interventions (with brief rationale) | met | not met |
Evaluation |
||
| Patient will exhibit no further skin breakdown during shift.Patient and family will explain skin care regimen for surgical incision sites before discharge. |
|
XX | Goal met. Goal met. | |||
| Nursing Diagnosis – Use PES format – (Based on the objective and subjective data from your worksheet) | ||||
| Nursing Diagnosis (Problem) r/t Etiology (What caused the problem) AEB Symptoms (Evidence of the problem)Deficient Knowledge r/t lack of exposure to Foley catheter utilization and care AEB by patient expressing need to know how to use the catheter after discharge | ||||
| Expected Outcomes | Interventions (with brief rational) | met | not met |
Evaluation |
| Patient will communicate understanding of importance of catheter care before discharge.Patient will demonstrate understanding of how to change to and use leg bag before discharge
Patient will communicate understanding of how to and reason to change back to regular urine collection bag during nighttime before discharge. |
Demonstrate proper catheter care for patient. Have patient repeat back these instructions and their importance during bath time.Prior to discharge: Demonstrate how to change from regular urine collection bag to leg bag. Demonstrate how leg bag is to be worn. Demonstrate when and how to drain leg bag. Teach the importance of keeping catheter connections clean. Have patient demonstrate these skills.
Prior to discharge: Demonstrate how to change back to regular urine collection bag. Explain the convenience and safety of using the larger bag for this long period of time. Have patient repeat back this information and acknowledge understanding. |
XX
X |
Goal met.Goal met.
Goal met. |
|
Student Nursing Study Blog 
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