The breakdown of care plans

Nursing Students Student Assist

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I'm working on my first really detailed care plan and I need some help with what the instructor is actually looking for in each heading. The headings I have to use are (left to right): Assessment and Diagnostic Data, Nursing Diagnosis, Client outcomes, rationale, interventions (which is then broken down into two columns, planned and actual), and Evaluation. I know the assessment and diagnostic data and nursing diagnosis. I assume client outcomes is the goal, for example the one I'm doing is on a bilateral total knee replacement patient and the diagnosis is acute pain so the outcome I have listed "patient will report pain q4 hours to keep pain within his pain goal" among other goals. The rationale would be that monitoring pain q4 hours allows the patient and nurse to treat the pain before it gets too high. The interventions have me stumped with them broken down into two categories. And evaluation would be pain was kept within acceptable pain goal limit set by patient.

Am I on the right track? What do I do for the interventions? I'm supposed to have rationale for every intervention and cite evidence based rationale.

(I'm using my med-surg textbook and the Ackley nursing care plan book).

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Alright, I'm sure one of the moderators of the site is about to go buck wild on a reply so I'll keep my post short and just post two examples of mine from nursing school for you to look at at the end, one is a basic care plan in the format you're kind of describing, and the other goes in more detail and is written out like term paper, but gives you an idea of how to word rationales and how to evaluate your steps.

Outcomes are events during care (kinda like milestones) that are measurable/quantifiable through assessment. They aren't exactly goals, but I could see why you would describe them as such. They are the steps or markers along a time line that you believe will help you prove that you are reaching a short term or long term goal of your care through the implementation of interventions you outline in your plan of care(you should have both short term goals and long term goals).

Basically for every outcome you set, you should list the actions you plan to do (interventions) to make the outcome happen. Some outcomes will only require one intervention, some outcomes may require multiple interventions. For every intervention you write, you need to have a rationale to back up why you think it's appropriate (this part always annoyed me, even as the debater I am)....

...and that's a quick review of some important elements of a care plan. If you have any other questions about specifics, lemme know, I don't wanna try and get this care plan done for you, these plans are a good skill to learn in terms of training you how to think, but I realize they kinda burn your brain out sometimes. Oh and your intervention list being broken down into planned and actual are only there for you because this care plan assignment is assigned to be completed WHILE you care for your patient and turn it in after...so you can only fill out that actual column after you know what you did during the care...that planned column is pretty much for all the tasks that you planned to do IDEALLY but either didn't get to, or couldn't find a way to complete...which during the evaluation column will allow you to verbalize why you did, or did not do interventions and how doing or not doing them effected your care overall. Clear?

Here are those examples I promised:

https://drive.google.com/file/d/0BzP_7cm_N-yaTjl3T0JYQkNic28/edit?usp=sharing

https://drive.google.com/file/d/0BzP_7cm_N-yaRDVaZ1lGQl9YWXc/edit?usp=sharing

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Couple more things, just as suggestions to either take or leave, but you using the term "acceptable pain goal limit", in my opinion, is pretty inappropriate verbiage. It might just be because you're at a loss for what to call it, but you might consider using "manage pain within an acceptable level as defined by the patient" or just the term "acceptable level of pain" rather than pain goal limit...it's just grammatically incorrect, mostly.

What do I do for the interventions? I'm supposed to have rationale for every intervention and cite evidence based rationale.

To spout of a few off the top of my head? Interventions to consider for acute pain management,

1. Always start with assessment and go from there: Assess the factors involved in patients pain. You won't be able to thoroughly manage this patients pain without figuring out what factors contribute to the onset of pain at an unacceptable level.

2. Evaluate response to the pain, or evaluate the response to pain management techniques already in place. What works for this pt in terms of pain relief? How does this patient cope with pain? All of this information can be useful in determining appropriate short term and long term goals, which may very well include education of alternative pain therapies.

3. Now that you've figured out how this patient responds to pain and what helps it: "Assist the pt control pain by [be specific: ex. administering [dosage of med] [name of med] as ordered, [frequency prescribed]"

There's just a few to consider...

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Couple more things, just as suggestions to either take or leave, but you using the term "acceptable pain goal limit", in my opinion, is pretty inappropriate verbiage. It might just be because you're at a loss for what to call it, but you might consider using "manage pain within an acceptable level as defined by the patient" or just the term "acceptable level of pain" rather than pain goal limit...it's just grammatically incorrect, mostly.

You're right, I just didn't really know how to phrase that so that it would sound appropriate and couldn't remember the terms that I'd seen in the chart.

I can see the value in the care plans and I think I will be able to write a pretty decent one now that I have an idea of what goes in each column. My biggest problem is I'm a person who has to see something and be able to take it apart and analyze it after I see it to understand how it works. Thank you for posting examples of your care plans and walking me through the information. That gives me a much better understanding of where to go with this and how to make it all work. I do this in head while I'm at my clinical site, but have a difficult time writing it out.

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I can totally relate, I felt like I had it completely figured out in my head, but when I went to write it down in a fluent, calculated way, it just came out a jumbled mess.

Talk it through, and write it all down in your own words before you try to tinker with the lingo into a more professional tone...it helped me immensely.

Really, I just replayed how I felt care should have been directed throughout the day based on what I was told at report when I was assigned to the patient...I noted the things that I particularly prioritized and rationalized why I did what I did or delayed what I did...at that point the care plan wrote itself. I was able to see what areas of the pt's care I was really focusing on, and I got to recall just why I thought the way I did.

Glad I could help!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Interesting..."Buck wild" ? and all along I thought we were helpful. Silly me.

First........Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

Your Ackley should have interventions listed that you can use to help guide you.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

  1. 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)

  2. 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)

  3. Planning
    (write measurable goals/outcomes and nursing interventions)

  4. Implementation
    (initiate the care plan)

  5. Evaluation
    (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis. Collection of data is important to your plan of care. These brain sheets may help......from daytonite....

‎critical thinking flow sheet for nursing students

student clinical report sheet for one patient

This is an excellent resource for examples for this format.....http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

Blank_Care_map.doc

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Specializes in Complex pedi to LTC/SA & now a manager.

My pediatric patients with pain issues usually have a goal of maintain pain level

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Interesting..."Buck wild" ? and all along I thought we were helpful. Silly me. First........Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient collect data then find a diagnosis. Let the patient data drive the diagnosis. Your Ackley should have interventions listed that you can use to help guide you. The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis. Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse. Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death. Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first. Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE [*']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) Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process. Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues. A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available. What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up. Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis. Collection of data is important to your plan of care. These brain sheets may help......from daytonite.... ‎critical thinking flow sheet for nursing students student clinical report sheet for one patient This is an excellent resource for examples for this format.....http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

No offense implied! I'm really sorry! I just meant I've noticed very prompt thorough responses to these types of questions from you in every thread I've opened. I think it's fantastic how quick and thorough you are in responding to these pleas for help!

If anything, I'm in training! I only hope to offer different strategies in hopes of meeting their learning style by either my answer or yours! Again no offense! I'm sorry! I love your buck wild responses :)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Where I come from Buckwild means insane or crazy....but I know you meant no harm....;)

Your responses are thoughtful and helpful....your contributions will be appreciated. Home work help is usually a timed thing so GrnTea and I try to response as quickly as we can....I like that you mkae them put their thoughts first....our goal is to lead them to so they may find the right answer.....find their own Ahh Haa moment!

Welcome!!!!

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Besides the NANDA-I 2012-2014, which you had better have :yes: :twocents:, I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now.

The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on page 475, you will find "tissue perfusion, peripheral, ineffective." This is followed by the lay definition of what circulation status is, major interventions for arterial insufficiency and venous insufficiency, and a long list of suggested and optional interventions from which to choose. It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon.

It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

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