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We are happy to help with homework but we won't do it for you. What do you have so far so I can see what your thought process is? What semester are you so I can better guide you? Did you spend any time with this patient? What were the patients complaints? Remember that your care plan is the plan of care for that patient. A recipe on what you need to think of, and do, for this patient. What did the patient say?what other considerations are there? What was assessment/interaction during your time with the patient? What symptoms did this patient present with?
The biggest thing about a care plan is the assessment, of the patient. not just physical assessment......but what the patient says, feels, interacts with their environment/family. 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 medical diagnosis is the disease itself. It is what the patient has
not necessarily what the patient needs.
The medical diagnosis is what the patient has and 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.
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 them as a recipe to caring for your patient. your plan of care.
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
. there are currently 188 nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. what you need to do is 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
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)