Hi, Deutsche_Nurse 75, and welcome to allnurses!
A care plan is the documentation of your problem solving effort on behalf of the patient. The nursing process is the problem solving method that we nurses use. It has five steps and you
MUST follow them
in sequence when you are care planning.
- Assessment (collect data from medical record, do a physical assessment of the patient, look up information about your patient's medical diseases/conditions)
- Determination of the patient's problem(s)/Nursing diagnosis (make a list of the abnormal assessment data, 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)
STEP #1 - Assessment
The first thing you need to do is STEP #1--Assessment. You need to gather together all the information that you collected on the patient. You should have done a physical assessment, observed them while you were doing their care and perhaps picked up a few more clues about them and done a thorough reading of their medical record for more clues. What you are looking for is abnormal data which, in reality, are what we are going to call signs and symptoms of the nursing problems that we will diagnose them with later in STEP #2 of the nursing process.
Another very important activity that I urge all students to do is to look up information about the medical diseases or conditions that their patients have. The reason for this is because many times you are seeing these conditions for the first time and you may have missed seeing signs and symptoms that were right in front of you. Reading up on them and double-checking is one way you learn about them. If you find you missed something, you want to add it to your assessment data. You also need to know what drugs, tests and treatments the doctors are normally going to order for these diseases. This information becomes important when you are working on your nursing interventions later on in STEP #3 of the nursing process.
STEP #2 - Determine the patient's problems/assign nursing diagnosis(es)
Once you have all that done, only then can you move on to STEP #2 which is where you identify your patient's nursing problems and assign nursing diagnostic labels to them. Those short 2, 3 and 4 word nursing diagnoses are nothing more than labels. The real nursing diagnoses are actually patient problems and are clearly identified in the definitions of each nursing diagnosis. I strongly urge everyone who is new at doing care planning and working with nursing diagnosis to use a nursing diagnosis reference of some type and to read these definitions before actually assigning any diagnostic label to a patient. You will find some interesting things in these definitions that the labels don't tell you!
From your assessment activities you want to now make a list of all the abnormal data that you found. These are signs and symptoms that your patient has. From here on, the remainder of your care plan is dependent on this list of symptoms. It is the foundation of your care plan. With it you will now look for nursing diagnoses that have defining characteristics (this is NANDA language for symptoms) that match. Diagnosis is
the resulting decision, or opinion, that you make after performing the process of examination or investigation of the facts. Lots of professions do diagnosing--it is not limited to doctors. A doctor is not going to diagnose anyone with a disease condition without having done an examination first. The same holds true for nursing diagnosis. We have to do our examination/assessment first and use that information to diagnose. We have help to pick our diagnoses--the NANDA taxonomy.
NANDA has compiled lists of signs and symptoms (NANDA calls them defining characteristics) for each of the 188 nursing diagnoses. All we need to do is to verify that our patients have one or more of those symptoms before we apply one of those diagnoses to the patient. You cannot diagnose any patient with a nursing diagnosis unless they have at least one or more symptoms of the problem.
In addition to the signs and symptoms NANDA has also included the definition and related factors (etiology or cause) with each nursing diagnosis in the taxonomy. Everything that you need to create a 3-part nursing diagnostic statement is in the NANDA taxonomy for each nursing diagnosis.
The 3-part nursing diagnosis statement has this structural format:
P - E - S
P = Problem
E = Etiology
S = Symptoms
or
Problem - Etiology(ies) - Symptoms
these are, in NANDA language
Nursing Diagnosis - Related Factor(s) - Defining Characteristic(s)
in a care plan they look like this:
PROBLEM [related to] ETIOLOGY(IES) [as evidenced by]SYMPTOM(S)
or
NURSING DIAGNOSIS [related to] RELATED FACTOR(S) [as evidenced by] DEFINING CHARACTERISTIC(S)
The RELATED FACTOR is the underlying cause of the problem or the cause of the signs and symptoms that the patient is having. To help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. To help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". Remember this important rule: you cannot list any medical diagnosis as a related factor. You have to state a medical condition in some other scientific terms. As an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". They essentially mean the same thing--the difference is in the phrasing of the words.
The DEFINING CHARACTERISTICS are always the signs and symptoms that come from that list you created from your assessment activities. These will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to ADL evaluations that were not normal.
STEP #3 - Planning
Once you have matched as many of your signs and symptoms to nursing diagnoses and determined your patient's nursing diagnoses to your satisfaction you can then move on to STEP #3 of the nursing process--the actual planning of nursing care. There are two activities involved here. The development of (1) goals/outcomes and (2) nursing interventions. Goals and nursing interventions are ALWAYS based upon your patient's signs and symptoms that were on the symptom list you developed from STEP #2.
There is a discussion on how to write goal statements on post #157 on http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html.
Nursing interventions are of 4 types: - Assess/monitor/evaluate/observe (to evaluate the patient's condition)
- Care/perform/provide/assist (performing actual patient care)
- Teach/educate/instruct/supervise (educating patient or caregiver)
- Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
And, with that, the majority of your care plan that you write to turn in to your instructors is completed. You can read this thread for another similar explanation of this process:
http://allnurses.com/forums/f205/help-nursing-care-plans-277791.html.
If you still need help getting started, post a list of your patient's symptoms and I will help you. A symptom is an objective observation that you or another examiner has made or a subjective perception made by the patient (i.e. verbal statements).
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