first of all, if you have read any of the information in the stickys:
then you know that every care plan follows the steps of the nursing process which are:
- assessment (collect data from medical record and by doing a physical assessment of the patient)
- nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
now, you've provided some very good assessment information (step #1). some things you need to do with some of that information is to look up information about cvas, etoh abuse and htn. you want to know what causes them, their pathophysiology, signs and symptoms, complications, how they are diagnosed and treated. pay particular attention to their signs and symptoms. you want to double check to make sure you didn't miss any of them in your patient. if you did then you need to add them to your assessment. also look up the normals for the lab values. a few of this patient's lab values are a bit abnormal and you want to know what the significance of these abnormal values are. there are links to lab references where you can get this information on this thread: http://allnurses.com/forums/f205/med...es-258109.html
. you also need to look up each of the medications that this patient is taking to verify that it is being given for the medical diagnoses that you already know about. if you find a medication being given for something you don't know about, then something was missing from the doctor's history and physical. it may or may not be important to know that information. also, with some medications, there may be important nursing implications that you might have to work into your nursing interventions in the care plan.
all right, having done that, you can now move on the step #2 of the nursing process which is to make a list of your abnormal assessment data. i did this from what you listed in your post.
- incontinent to bladder/bowel
- difficulty swallowing
- decreased appetite
- left side weakness
- needs maximum assist with self-care
- wheel-chair bound
- huge stage iii decubitus that is not draining and gets a wet to dry dressing
- wbc is 10.6 (normal is 5 - 10)
- hg 11.6 (normal male is 14-18)
- hct 33.8 (normal male is 42-52)
- platelets 769 (normal is 150-400)
- na 134 (normal is 136-145)
- has c. diff
now, what you have is a list of symptoms (nanda calls them defining characteristics). i call it a shopping list. you need a nursing diagnosis reference of some sort because it's now time to go shopping for nursing diagnoses. you are looking for diagnoses that have some of the same symptoms (defining characteristics) that this patient has on this list. this patient will at the least have diagnoses related to incontinence, mobility, swallowing and skin integrity.
as for your care map, a care map is just the physical way you are going to present this information. you will find information about care maps and some student examples of them on this sticky thread:
if you are still having trouble picking a nursing diagnosis or formulating your nursing diagnostic statements, post your questions and i will give you more help.