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NurseWords.com
dictionary of nursing abbreviations and acronyms
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When you inquire into a nursing care facilities plan, they give you the idea that everything is going to be the best thing you can possibly do for someone who needs help. You receive all kinds of deceptive literature of how well your loved one is going to be cared for and in many cases it just is NOT true! Some nursing homes are better than others and overall, they tend to have a very high turn-over because of lousy pay and having to deal with elderly people that might be hard to get along with because they are physically or mentally ill (or both). Many people that work in nursing homes can only take so much of this type of pressure before they snap at or hurt a patient. Unfortunately, I have been in this situation and what I thought was going to be better than average care was pretty minimal at best. If I could have possibly taken care of my ill relative, I would never have put them in a nursing home. I can not begin to tell you how horrible and lonely of an experience it can be for a loved one. Do lots of research and if you decide on one, pop in unexpectedly every so often and see if they are living up their empty words and promises.
Interventions are what things will you do to/ for the patient that relates to their nursing diagnosis. EX: Monitor vital signs and responses to activity.
The rationale is Why you do these things. Ex: Monitoring enables the nurse to determine current tolerance to activity.
The evaluation is the things you witness and how you know if your interventions are working. Ex: Client was able to ambulate to hallway with no shortness of breath or distress.
I hope this helps I don’t know if your care plans are similar to mine or if your program requires different things.
care plans are usually set up under specific sections
just organize what is neede d and address each intervention in an orderly matter
dx- nursing actions
relating to problems or potential problems related to the dx
expected and time oriented goals and outcomes of all areas and if those measures were successful
Adl abilities of the patient specifying what each patient is able to do himself and specific assistance needed in each area( bathing-dressing- eating-toileting-transferring- turning and positioning etc.)
medications
use
desired effects
adverse effects
potential hazards of use ( drowsiness- dizziness etc)
need for adaptive devices
any physical handicaps
any sensory deficits and use of glasses-hearing aids)
ensuring proper nutrition and hydration( include diet any dentures or fluid restrictions or need for i&o)
adressing any behavorial problems
adressing ability to communicate needs and primary language spoken
in NY state nursing homes do a form called MDS
each area triggered as a problem or potential problem is addressed at least quarterly and the interdiciplinary team discusses the patient and at the annual review the family attends
each area is discussed and updated by the interdiscinplinary team and the item is resolved
continued or discontinued as it was not effective and a new plan is put in place
in the hospital care plans are usually reviewed and updated every day and as needed
each facility has a different care plan format
some are forms with patient info on front and blank pages added for each issue and intervention andtime specific goal
some like one i worked in had pre printed sheets that matched each tigger in the mds with combination of checklist and areas to write in whatever else was needed
in the hospital the care plan was part of each patients Kardex
the facility you work in has policies and procedures to follow for initiating and maintaining a care plan
it takes time and thought to cover everything you need to include
remember anything in that care plan has to be followed and kept up to date
when survey teams and facility inspections occur the inspectors randomly pick patients and check their care and progress by what is written in the care plan
not following it or omitting important information can leave you and the facility liabel
the care plan gives everyone a picture of the pt. his needs
your goals and the means you used to attain those goals
it gets easier with time
just learn your facilities care plan structure
do not be afraid to ask others with more experience for help and in no time it will be second nature
good luck