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Care Plan Part II Assignment: Instructions Components of Part II
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Body of Part II Base Part II on the data and diagnosis made in Part I. Review the guidelines for writing care plans. Begin Part II at the Client Goals. Use headings in Part II as you did in Part I to highlight the steps of the Nursing Process. Use your last name as a running header and number the pages. Read the sample for Part II. Within the sample, suggestions are in italics. Goal # 1 ( short term ) For the purposes of writing care plans in nursing school pick a short term goal that you can evaluate while you still have access the the client, and before you have to write up your care plan. MC will (Always start with a version of "The client will . . .") actively seek help in the area of nutrition ( getting groceries, preparing meals, eating with someone ) at least once a week (note the frequency of measurement) until noon on November 14. (note the date set for final evaluation of goal #1 ). To measure this goal MC will be questioned once a week about seeking help . If she gives an example of seeking help during the week, then the goal will be considered as met. (note how the evaluation process is spelled out here even before any action is taken by the nurse or nursing student) Interventions (Note that these are actions taken by the nurse / NS ) for Goal #1 Rationale follows each intervention to support the nurse's choice of action. The interventions use the information gathered about the etiology of the human response to try to improve the situation. 1. Encourage family members to bring food with them when they visit. Rationale : It is difficult for MC to grocery shop. Often there is very little food in the house. 2. Encourage family members to visit at meal times and ask MC to eat with them. Rationale : MC eats less when she is alone. 3. Encourage MC to pay to have food delivered at least once a week. Rationale: The cost of delivery is minimal compared to the effort MC must make to shop for herself. 4. Support MC's continuing inquires about getting a live in student who is willing to shop and cook in exchange for lodging. Rationale : MC has used this kind of help before and it was mutually beneficial to MC and the student. Since this is a long involved process, MC must persist in her inquiries to get someone. For the short term goal, only list actions that you did carry out. Save your additional ideas for interventions for the goal revision part of an Evaluation section. Evaluation of Goal #1 Goal #1 was that MC will actively seek help in the area of nutrition at least once per week until Nov. 14. MC was to be questioned once per week. Note restatement of the goal. MC was phoned each week following the initial interview, and encouraged to talk about her eating, getting groceries, and her visitors. The last call was made at noon on November 14. The findings were that she did ask for or respond positively to the help of relatives or friends once or twice a week each week. MC also reported refusing to eat during some visits by her son, stating that she did not feel well. The goal as stated has been met. The interventions that supported this goal seem generally to be working. This is the end of the short term goal section. Notice how the goal statement, the interventions, and the evaluation follow one another. Now repeat the same sequence for the long term goal section. Goal #2 ( long term goal ) The long term goal should relate to the human response part of the Nursing Diagnosis. You will not be able to do a final evaluation of this goal because the time for evaluation is set past the due date for your plan. MC will increase her weight by an average of 0.5 pounds a month for the months of November, and December. The goal will be evaluated at 6 PM on January 1 using MC's bathroom scales. (Note that the goal is very specific about the time frame, and how success is to be measured.) Interventions for Goal # 2 with rationale 1. Continue the interventions written for Goal #1 Rationale : The interventions seem to be working. 2. Encourage family members to send gift baskets of snack food each month Rationale : Gourmet foods can be tempting. MC is thrifty, and does not like to see food go to waste. 3. Encourage family members, and friends from her church and historical society to take MC to holiday activities that involve party food, keeping in mind that she tires easily. Rationale : If the party is long or far away, MC will refuse to go. She does enjoy seeing her family and friends if she does not have to prepare food. 4. Be careful not to seem to focus on her eating when talking with her. Rationale : MC does not want others to dictate what she should do. She will turn a deaf ear if she feels someone is "preaching" to her. Note that these rationale are logical reasons based on knowledge of this client. If you reasoning came out of a book, you must cite the source. Evaluation of Goal #2 Goal #2 was that MC will increase her weight by an average of 0.5 pounds per month for the months of November and December. The final evaluation of this goal is January 1. At the present time MC 's weight has remained unchanged since the time of the interview. Since she had lost 7 pounds in the prior four months, holding her weight steady is an improvement. However if the goal were measured now, the goal would not be met because the goal calls for a weight gain of 0.5 pounds in November. It is clear that the interventions for Goal #2 need to be added to those actions that supported Goal #1 for MC to start gaining weight. Based on MC's lack of weight gain one more intervention will be added : 5. Encourage MC to buy milk in quarts rather than in half gallons. Rationale : MC's torn rotator cuffs make it difficult for her to lift. If the milk is not so heavy to lift out of the refrigerator she may be more likely to pour herself a glass. CHL: 11/96 10plan |