A nursing care plan is the written documentation of the nursing process. The nursing process is nothing more than a problem solving method that we use. You follow the same steps to write a care plan that you follow to perform the nursing process:
- Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- 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 diagnoses to use)
- Planning (write measurable goals/outcomes and nursing interventions)
- Implementation (initiate the care plan)
- Evaluation (determine if goals/outcomes have been met)
If a client was having an appendectomy and has diabetes what kind of precautions need to be taken?
What you need to do is look up information on an appendectomy (
http://www.surgeryencyclopedia.com/index.html) and diabetes, particularly complications. You also need to know what happens during general anesthesia and the possible complications
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- constipation
- surgical pain
- nausea/vomiting (paralytic ileus)
and how it might have an affect on someone with diabetes (i.e., patient is generally NPO for 9 hours before surgery. How does that affect his diabetic condition? If the patient has circulatory problems to the lower extremities as a result of their diabetes, how does that affect surgical care if the patient is lying still for a long length of time?). You have to look at these connections.