A care plan is an organized and structured plan that addresses the problems that a patient has to deal with. A basic nursing care plan, in particular, addresses how a patient is going to be able to accomplish their daily activities of living (ADLs). This is primarily what nurses do. In working up this care plan you also have to consider the person's underlying medical, physical, social, cultural and personal resources and conflicts that might impact their care. There is an established process to do this. It is called the nursing process. A written plan of care is based upon the nursing process. It includes the following steps:
Assessment (collect data)
Nursing Diagnosis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)
Your scenario has provided you with some of your assessment data for the first step of this process. However, it also brings up some questions as well and I've written a few in brackets:
fractures of both wrists and right femur
needs to be on crutches for the next 6 weeks
smokes 20 cigarettes a day [how's he going to get cigarettes when he runs out?]
drinks alcohol on a regular basis [how regular and how much?]
depends on takeaway food for meals [any food in the house? Does he cook? How will he get groceries?]
will need to be goes up stairs in his house to get to his bedroom
the bedroom floor is carpeted [crutches and carpet don't do well together; is it possible the patient can sleep downstairs somewhere?]
the shower and bathroom are upstairs attached to the bedroom [question: is there a bathroom downstairs?]
steep driveway which will make getting in and out of a vehicle a potential problem [was the motorbike ruined? Is there another vehicle? Is the patient even going to be able to drive? How will be get to doctor appointments, the store?]
Did your nursing school provide you with a list of ADLs? I have a very basic list, but it may not be the same as the one your school wants you to use.
- eating and drinking
- toileting
- bathing
- dressing
- ability to move and get where they need to go
- communicate
- sleep and rest
diversional activity
To complete Step #1 of the nursing and care plan process I would assess this patient for each of the ADLs I listed (or use the list your school wants you to use) against the information you were given in the scenario.
You start by asking yourself what difficulties do you see Luke having with eating and drinking. Well, he has two broken wrists and most likely will have casts or splints on both. He may or may not be able to hold utensils to eat food. That might be a problem for him. Since he likes takeaway food (obviously he doesn't cook much, I think) how can he get to the stores he goes to and buy this food. It's not likely that he's going to be able to drive very well, if at all, with two casts on his forearms. With a cast on one leg he's going to also have a hard time getting onto his motorbike (if it is even working!) or a vehicle since his vehicles are parked on a slope and he's hobbling around with crutches. So, how is he going to get food and eat it?
Get the idea? You go through each of the ADLs and assess Luke's condition and situation against them and determine what kind of abnormal conditions he's got to deal with now. Compile a list of all these problems. These become the focus of your care plan. You can now move on to Step #2 of the nursing and care planning process.
Step #2 has recently become the identification of nursing diagnoses but it is also the determination of what your patient's major nursing problems are. If you are being required to use nursing diagnoses most of them will be Self-care deficiencies and mobility ones, but there may be others. If you are not required to use nursing diagnoses, you will merely list out problems related to each of the ADLs that the patient is going to have difficulty with. He may or may not have a communication problem so that one may not be one that needs to be addressed, unless, of course, he might have trouble ambulating to the telephone!
Once you have determined and listed these problems, Step #3 is to do the actual nursing interventions to help assist the patient in resolving these problems. In most cases your goals are going to be for the patient to achieve each ADL. In many cases you are going to have to help the patient modify the way he currently has done his ADLs to take into account his now limited mobility. This is where nursing becomes creative. Think about what you would do if you had a cast on both your arms and one leg, couldn't cook and were stuck in the house, probably not able to work for 6 weeks or so.
And, that covers the first three steps of the care planning process. That's about 75% of the work that has to be put into a care plan to begin with.
You can see more about care planning and how the process is put together on these threads of allnurses:
If you are still having difficulty with this, please ask for more help. Good luck!
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nursing care plan help
. it is a tough assignment since not too much info is given and no assumptions can be made! 
