Desperately need help with careplans

I bought a wonderful book about 5 or 6 years ago to help me write some care plans at a nursing home I was working at. I still have it and occassionally refer to it. It is Nursing Care Plans and Documentation: Nursing Diagnoses and Collaborative Problems, Third Edition by Lynda Juall Carpenito. When you get beyond the title it has some very good information in it. It is organized by the NANDA diagnoses. For each diagnosis it gives you outcome criterias, what to focus your assessment on and its clinical significance, and interventions with rationales

At our school, we can't reference the actual care plan books but can use them for guidance to setting up the plan and the interventions & outcomes. We actually have to use our assigned nursing texts and reference those pages. They must be specific to the patient's condition and your interventions. It sounds like a pain but I've learned so much this way. but like I mentioned, I do use a care plan book for guidance only. Good luck.

Other great links:

Individual Care Plans Fully Developed

Nursing Diagnoses with Defining Characteristics

http://www.indstate.edu/mary/nanda.html

Overview of NIC/NOC
Nursing Interventions Classification(NIC)

Nursing Outcomes Classification (NOC)

PowerPoints:
Chapter 12: Assessing
Chapter 13: Diagnosing
Chapter 14: Outcome Identification and Planning
Chapter 15: Implementing
Chapter 16: Evaluating

We have a test on Tuesday. Here's the criteria:
Criterion PossiblePoints Student Points Comments
· Data/cues are clustered appropriately. 3
· Three (3) Nursing Diagnoses are formulated based on the clustered data. 3
· Diagnostic statements are written according to NANDA guidelines. 3
· Diagnostic statements do not contain prejudicial or legally inadvisable statements. 1
· Nursing Diagnoses are appropriately prioritized 2
· Day of Care Goal/Outcome is correctly stated. 2
· Discharge Goal/Outcome is correctly stated. 2
· Three (3) nursing interventions are listed that are appropriate for the desired outcome(s). 2
· Scientific rationales for all nursing interventions are stated and referenced. 2
· Total points 20


I was freaking out about this,but then I realized that all the information I needed was right in my book. It is called "Clinical Applications of Nursing Diagnosis" fourth edition by Helen C. Cox. The Taber's Publisher. Go to www.fadavis.com for info. on this book. Once you figure out how to use it, it's real simple.The possible nursing diagnoses are on the back cover, which gives you page numbers to look them up. When you look up each page number, it provides Definitions, defining characteristics (which can be compared to your cues from your scenario) Expected Outcomes, Target Dates,nursing actions & interventions with rationales, and outcome flowcharts.
We also used "Applying Nursing Process: A Tool for Critical Thinking" by Rosalinda Alfaro-LeFevre by Lippincot Wililams & Wilkins. This picks apart the entire Nursing Process & explains each step.
Hope this helps!!

http://kcsun3.tripod.com/id225.htm


Check this website out ! lots of good help

http://www.careplans.com/pages/problemlist.asp

Good resource: Nursing Careplan for a Client with Multiple Sclerosis:

http://www.cnsonline.org/www/archive/ms/ms-07.html

Prioritize according to ABC's and Maslow's Hierarchy.

Depends on how stable the patient is and when the 2nd and 3rd degree burns occurred. If he is a "fresh" burn patient, then airway and electrolyte imbalances take priority. Of course, pain issues also are priority throughout the course of care.

http://www.ncbi.nlm.nih.gov/entrez/q...&dopt=Abstract

Check out this website: http://www1.us.elsevierhealth.com/ME...nstructor/#New

It's a free care plan constructor based on the book Nursing Care Plans by Gulanick, et al. The authors provide understandable explanations of each nursing diagnosis, and their interventions are heavily oriented towards assessment.

I used to get stuck on coming up with enough appropriate interventions, until I started focusing on assessments.

By the way, you can pick up used copies at either Amazon or Alibris.com.

Good luck!

Hepatic Encephalopathy is also known as coma resulting from liver damage. A high mortality rate is associated with this disorder, and the cause is unknown. (Source: Med Surge textbook).

Two major groups of signs and symptoms you'll be assessing for are neurological and respiratory (remember, the brain controls the respiration rate).

I'm going to assume your patient has lung sounds, let's say crackles, and a productive cough. This is your "as evidenced by".

So your nursing diagnosis is "Ineffective Airway Clearance related to depressed central nervous system function and dyspnea as evidenced by crackles and productive cough."

For goals, pick a measurable repiratory sign, like "O2 sat will remain above 90% during hospital stay" or "respiration rate will remain at 15 per minute throughout stay."

This gives your first two interventions: 1) monitor O2 sat Q2H; and 2) monitor respiration rate Q2H.

Now come up with as many more interventions as your teacher needs, mainly neuro or respiratory. Here's some for starters: elevate head of bead; auscultate for lung sounds; monitor for signs of dyspnea such as nasal flaring, use of acessory muscles, anxiey, & retractions; humidify and push fluids in order to thin secretions; assess pupil size and reaction; assess level of consciousness using Glascow coma scale; assess grip strength; assess reflexes. Of course you also want to assess for pain, administer meds, and check lab values too. You can teach deep breathing & coughing, and also explain why you are doing the assessments you are. Explain something about the pt's medications.

That should get you started. Other good diagnoses might be Activity Intolerance (cardiovascular deconditioning), Impaired Skin or Tissue Integrity (pressure sores from decreased mobility and bed rest), or Constipation (lack of motility due to inactivity or medications).

Good luck!