Glimmer. . .as someone who has written a lot of care plans
, I specifically did a lot of study over this past summer of NANDA and had my head buried in a number of care plan books. My goal was to be able to help you students with your care plan writing when you were asking questions here on the forums.
If there is one thing that was very clear to me about the care plan process it is how one arrives at choosing nursing diagnoses. I struggled with this when I was a student some years ago myself. But, I can tell you with a great deal of confidence now that it all starts with the data that you collect on your patients. It doesn't necessarily have to be what you got from your own assessment. It can be data from what the doctor had to say or lab and x-rays. Anything that you cannot say is "normal" can be tagged as a patient problem that nursing can, hopefully, address and do something to help the patient with. When I was in nursing school 30 years ago, we just listed these problems one-by-one and put nursing interventions with them on our care plans. Today, NANDA wants us to group the problems and put labels on them called nursing diagnoses and then put nursing interventions with them. It took me 20 years and a lot of reading this summer to realize that very simple distinction between my training 30 years ago and what you are being taught today.
NANDA has actually given nurses guidelines in how to choose nursing diagnoses. The one care plan book that I am familiar with that lists these guidelines is the one by Ackley and Ladwig. They went one step further and created an alphabetized index to help care plan writers cross reference symptoms with possible nursing diagnoses. Otherwise, you have to memorize all the stuff. I also obtained a copy of Nursing Diagnoses: Definitions & Classification 2005-2006
published by NANDA International which has that information, but without the nursing interventions and outcomes printed in it.
The only way I can see to make this process easier to for you is for you to put each abnormal assessment item from a patient on an index card and start sorting these cards into piles that will eventually become a nursing diagnosis. You would have to do this for each patient. Students that are being taught care maps are doing care planning this way.
One of the biggest problems I am seeing as I respond to students asking for help with care plans is that they have missed important data. Often they didn't review the chart completely. But, even more complex is that they did observe something in their patient, but didn't realize that it was an abnormal symptom, so it didn't get written down in their notes. This is just due to inexperience. That is something that has to be discovered from re-reading descriptions of the pathophysiology of disease states. This is why I will often list links to information about certain disease conditions along with answers in some of my posts. I can't know what a student has missed in observing their patient since every patient is unique. I can only guess what might have been missed based on my years of experience.
The handful of care plans that you will write as a student are only an introduction to the skill. It will by no means make you a master at it. But, hang in there and put your best efforts into them. There are many things to learn from care plan writing: critical thinking, knowledge of the disease process and knowledge of nursing care.
I applaud your efforts to hone your skills. Keep at this. Practice makes perfect as we all know! :1luvu: