Quote from rnn2008
can someone help me please... i'm so confuse with these care plans. i'm starting my first clinical orientation on sept.5 and by sept. 6 we are suppose to bring in a care plan. the thing is that, i'm so clueless on how to do a care plan and my instructor(s) really haven't gone over it much with us. the only thing they gave us is a sample care plan written by some former student. i'm having a nervous break-down right about now. i don't want to show up to clinical just to be sent home for incomplete care plan.
my question is how do we find out what to put into the care plan... ie. nursing dx, outcome criteria, nursing interventions, rationales, and evaluation? is that suppose to just "poof" out of your own head? are we suppose to just know those off the back of our heads or something? how are we suppose to know what to put into a care plan? help! help! help!
wow! i am really sorry you haven't gotten any help with this. i am assuming that you will know who your patient is going to be the day before you show up for clinical, otherwise how could you come in with a care plan for a patient that doesn't even exist? so, based on that premise this is what you will do. . .
remember, the nursing process (1) collect data (2) plan (3) intervene (4) evaluate. this is an ongoing process. you work with what you have available. so, the day or night before your clinical the only data you will have is most likely what you are going to be able to get from the patient's chart. so, you take some blank paper with you and get information from that chart. look at the physician's history and physical and any consultations. read through and copy all the doctor's orders in chronological order. read through all the doctor's progress notes (hopefully, you can read their writing!) and look for little gems the doctor has dropped that are clues to the doctor's plan of care. read over any operative or special procedure reports to see what was done, taken out, etc. then, look through the x-ray and labwork and copy down those results. if you noticed the doctor ordering daily ptts, specifically look for those results in the lab section because there is a reason he is doing that. at home you can figure it out. lastly, look through the nursing records, specifically the medication sheets (particularly look at what they have been giving the patient on a prn basis) and the nurses notes to see what kinds of problems they have been encountering with the patient. look for fevers, high b/ps and other problems
the nurses might have been having with the management of the patient.
now, at home. . .
you are going to take all this information and assemble it into a care plan for this patient. let me say that your final care plan is most likely going to change. the reason is because one very big component is missing yet. that is your
assessment. but, you won't get to that until you see the patient at clinical on sept 5th and 6th. right now, just work with what you got from the chart. what you are primarily interested in is the problems
the patient is having. you will be clued in to some of these problems
from the nursing notes, the medication record, the doctor's history and physical, x-ray reports, labwork, and the doctor's orders. with medical diagnoses you need to know what the common symptoms of those diagnoses are and look for them in the patient. some of those symptoms you found in the chart for that patient (refer to the doctor's history and physical) are going to become the problems
you are going to address in this preliminary nursing care plan.
list the problems
. group them into nursing diagnosis groups. a good recenly written care plan book can help you with this. if you have trouble though, either pm me or post a new thread for help on this forum. i realize your time span is very short (less than 24 hours), but you cannot put a nursing diagnosis on a patient without knowing what problems they are actually having
. write your nursing interventions for each of the problems within the nursing diagnosis. your outcomes can be very vague, but reflect the opposite (or resolution) of the nursing diagnosis. boom! you have your preliminary care plan and you are not going to be sent home.
after your clinical days you will add your own assessment data that you will have done on the patient to add to all of this.
- this is a care plan guideline from the nursing department of fairleigh dickinson university with instructions on composing your diagnosis, goals, interventions and evaluations. includes links on suggestions for conducting interviews with patients and gordon's 11 functional patterns.
- this page of links will allow you to view three sample care plans (activity intolerance, functional incontinence, and knowledge deficit) along with a printable template for the care plan. the lower part of this page has nursing care plan guidelines, information for putting together a care plan. from california state university at fresno.
good luck! free free to pm me or post a reply regarding this process. i will help you along, but i won't do all your work for you!