How to make nursing care plan (nanda)

  1. help! help! help! hoping someone will help me. I am a student and no experience yet. Everyone's help is highly appreaciated.
    My teacher hand us a case study and NCP form and i dont know how to start a nursing care plan using nanda approved nursing diagnoses. this is the case study. and at the bottom NCP form.

    Mary is doing a clinical rotation in anursing home. This morning, part of his assignment is to care for Mrs. York, a newly admitted, 82 yrs old pt.
    Mrs. York came to the skilled nursing home facility after a short hospitalizationfor malnutrition. She is a retired piano teacher who has been living independently since her husband's death 10 yrs. ago. Three months ago, after her bout with "flu," her appetite and strength diminished. She lost 20 Lbs., w/c led to her hospitalization.
    Mrs. York has three sons who visit regularly and are supportive of her returning to her home when her strength improves and her nutritional intake is stable. She is a pleasant woman who is cooperative and agreeable with the current plan for her recovery. Her sons describe her as extremely sociable; she enjoys numerous activities and interactions with others. The nurse, however, have observed her interacting very little with other residents and spending much time in he room alone. When aked about this apparent change in her socialization pattern, Mrs. York says she just doesn't want to bother people by asking them tp repeat things she can't hear. She is very hard of hearing. She admits that her hearing has gotten worse since the flu and that she should have it checked. However, she assumed she would have wait until she got home to make an appointment with an ear specialist.
    Mrs. York is alert and oriented. her medical diagnoses are Osteoarthritis and Malnutrition. Her current medications are ibuprofen 200 mg qid and multivitamins 1 qd. She wears glasses for reading and has her own teeth. Her vital signs this morning were: B/P= 106/78; Pulse= 76; Respiration= 18; Temp= 98.7F. She has no edema or shortness of breath and no history of smoking or alcohol abuse. Her present weight was 95 lbs. with a height of 5'4", her ideal body weight is 120 lbs +- 10%. Before the flu, her weight was 112 lbs. Although she gained 3 lbs. since arriving at the nursing home, her appitite is still poor to fair. She consumes 50% to 75% of meals. She is continent of bowel and bladder and denies problems with constipation. She had a lot of diarrhea during the "flu" and for 1 week thereafter. Mrs. York continues to experience decreased strength and stamina since the flu. but is improving with physical therapy five times per week and increased food intake. Her gait is unsteady and her balance is poor during transfer from wheelchair to bed. She is able to bathe and dress herself with moderate assistance. Her skin is intact but fragile.

    This is the NCP form.

    Patient's Problem:

    Nursing Diagnosis:



  2. Visit tucker2008 profile page

    About tucker2008

    Joined: May '08; Posts: 2; Likes: 1


  3. by   Daytonite
    you had no instruction whatsoever on how to write a nursing care plan? none at all? please read the information on how to write a care plan on this thread in the general nursing student discussion forum:
    you start by going through the assessment data you have been given about this patient. assessment is the first step of the nursing process and for care planning includes

    • a physical assessment of the patient (this information was given to you in the scenario)
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease (this information was given to you in the scenario)
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians (not applicable for this assignment)
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    the patient's problems are the same as the nursing diagnoses. a nursing diagnosis is merely a label that conveniently describes in a few words what the problem is. every nanda nursing diagnosis has a much longer worded definition which is the actual description of the patient problem that is being addressed. you cannot determine what this patient's problems/diagnoses are until you have completed the assessment and singled out and made a list of all the abnormal assessment data. all nursing diagnoses are based upon abnormal assessment data, better thought of as symptoms. those symptoms, or abnormal data, are also the basis for the goals/outcomes and nursing interventions.

    i will help you with this, but you must do some of the work. start by going through the scenario and listing the abnormal data. look up the pathophysiology, signs/symptoms, complication and medical treatment for osteoarthritis and malnutrition. include the signs and symptoms of osteoarthritis and malnutrition on the list of abnormal data.
  4. by   kamelkillr

    I am in the same boat with learning the care plan... it is different from the way I learn years ago when I started out as a flight medic.

    We did not go over the "how to's" in class so I am just winging it. Good luck to you Tucker... you are not alone in that situation.

  5. by   lahana24
    hello i'm a nursing student as well. i would start out with the priorities of the patient which is nutrition. then i would move to other things like her lack of motivation to interact with others and her osteoporosis. but, hey that's how i would do. other would probably say that the priorities is something else. but i do think your nursing instructors would've briefly went over how to do a care plan.
  6. by   Marty-Mar
    This is extremely helpful, thank you for taking the time to post this.