I'm pretty sure we have weblinks to sample care plans posted on one of these two care plan threads, probably
Desperately need help with careplans, but I don't know which post # they are on, you'll have to look through the various posts and there are currently over 100:
However, I can tell you from a lot of experience that looking at sample care plans and actually getting down to the business of writing one are two very different animals. It's like watching someone ride a 2-wheeler bike and then you getting up on one for the first time and doing it. You really have to get an understanding of what you are trying to accomplish in writing a care plan or you will never get a grasp of what you are doing with them--and you don't want that, do you? Care planning is a skill. Like any skill it takes practice which means you'll have to do quite a few of them to get proficient at it. The first ones will take more time and effort than later ones you do, but it will pay off in the long run.
Read the post I made to this thread a few days ago. It explains a lot about doing a care plan: http://allnurses.com/forums/f205/help-nursing-care-plans-277791.html
Since you have your assessment information, then you have completed STEP #1 of the care plan process. Did you also look up information about your patient's medical diseases? This is important as well. You need to know the pathophysiology of the patient's medical disease(s) and condition(s) in order to make the connection between the causality of their signs and symptoms and their nursing problems. This will become extremely important for STEP #2 of the care plan process when you are putting together your 3-part nursing diagnostic statement. You also need to look at what the signs and symptoms of the patient's medical disease(s) are as well to make sure you didn't miss noticing any of them when you did your assessment.
In STEP #2 of care planning you need to make a list of all the patient's abnormal data that you collected. This becomes your list of symptoms. It becomes the foundation of your care plan. It is from this list that you begin to determine what the patient's problems are and start to assign nursing diagnoses. It is also from this list that you develop your goals and nursing interventions for STEP #3 of the care plan process.
A note about nursing diagnoses: The two or three word nursing diagnoses that you use are merely labels. The real meat of any nursing diagnosis, which is really your patient problem, is in the true definition of the nursing diagnosis. Every nursing diagnosis has a much longer worded definition that much better describes it. With a nursing diagnosis reference you can read what these definitions are. They help you make a better diagnostic choice. [If you do not have a one of these, there is some limited free references on the Internet - they are listed on post #109 of the Desperately need help with careplans thread] Also, each nursing diagnosis has a list of signs and symptoms. In assigning a nursing diagnosis to a patient, you should check to make sure the patient has at least one if not more of these signs and symptoms. If they don't have any of the symptoms listed under a nursing diagnosis then you legitimately can't tag them with that diagnosis. A doctor couldn't fairly say you had hepatitis based on your single complaint of a little pain in your right side if you didn't have jaundice, darkened urine, an enlarged liver, clay colored stools and the lab work to match. You'd think he was nuts, fire him and go to another doctor! We need to take nursing diagnosis just as seriously.
If you are stumped by how to get your nursing diagnoses picked, post a list of your patient's symptoms and I will help you with that part of your care plan. A symptom is an objective observation you or another examiner [a doctor or another nurse] has made or a subjective perception (i.e. verbal statement) of the patient. Make sure you also assessed the patient's ADLs (activities of daily living) and their ability to perform them.
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Need Information - My First Care Plan- Help! Please!
