care planning is based on determining what the patient's nursing problems are. this is done by using the nursing process which consists of 5 steps, the first of which is assessment
. the entire care plan is based on everything that was discovered during assessment. that is the critical thinking or logic of care planning. this is why your instructors are counting you off for not having enough assessment data. nursing interventions are supposed to target the abnormal data that was discovered during the assessment process; that abnormal data is the evidence that supports the nursing diagnoses. all nursing diagnoses, like medical diagnoses, can be broken down into the patient's signs and symptoms to tell a story about the problem. your interventions are solutions to do something for each of those signs and symptoms because that is how you eat away at the problem in correcting it. doctors do the same thing in treating disease. the instructors can tell from the way your care plans are constructed that you are not utilizing the nursing process.
the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.
the third is a good care plan book. i use ackley: nursing diagnosis handbook, 9th edition and gulanick: nursing care plans, 7th edition
here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
- assessment (collect data from medical record, do a physical assessment of the patient, assess adls, 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)
plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is
a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.
just like you need a recipe care to make a cake from scratch. a care plan is your recipe card to caring for your patient and what to look for while you are caring for them.