all care plans follow the nursing process. so, you need to know the steps of the nursing process. they are:
- nursing diagnosis
you begin by doing an assessment of the patient and gathering as much information about them as you can find. this will include going through their medical record, reading what the doctor has written, reviewing the various test results, performing your own physical assessment and interview of the patient as well. you do all this in order to determine what, if any, symptoms and problems the patient has. most nursing programs have often given you lectures or had you take a class on assessing the patient. you may have a form that you are to follow when assessing the patient. you will find a link to one that you can open up and print out attached to the bottom of my reply (it's titled student clinical report sheet for one patient
after completing your assessment of the patient, you move to the next step of writing the care plan--determining a nursing diagnosis. this is done by deciding what the patient's nursing problems are. that is done by going through all the information you collected during their assessment. you make a list of everything that is abnormal. you should also look up the pathophysiology of an mi (myocardial infarction) in a textbook. find out what the textbook signs and symptoms are of an mi and see if your patient exhibits any of those same signs and symptoms. did you miss any when you did your assessment that you might want to add to all your information? you can't make things up that the patient didn't have, but sometimes when you are very new at doing this, you miss noticing symptoms in your patient that can be important. and, you don't want to forget anything. this is also how you learn and become better at assessment.
once you have this list, you need to take those abnormal assessment items and match them to the symptoms of some nursing diagnoses. each nursing diagnosis, no matter what nursing diagnosis system you are being asked to use (nanda is the most common one), has a definition and signs and symptoms (nanda calls them defining characteristics
). nanda also lists causes and etiologies (nanda calls them related factors) for each nursing diagnosis as well. you look at potential nursing diagnoses and see if any of your patient's abnormal assessment items, which you should now start to call symptoms, match any of them. if they do, then they are possible nursing diagnoses that you will use in this care plan. you also need to consider what the definition of each particular nursing diagnosis is to make sure that it fits to your patient and what is going on with him.
once you have determined your nursing diagnoses, you move onto the third part of the care plan which is developing goals and nursing interventions. these are based strictly on all the abnormal assessment items (symptoms) that you found way back when you were doing your assessment of the patient. by now, the patient's symptoms have been distributed out to one or more nursing diagnoses is all. most nursing care plan books call this process of matching patient symptoms with nursing diagnoses as grouping.
however, your goals and nursing interventions are going to be based upon these individual symptoms no matter what nursing diagnosis they are now associated with. goals are what you predict are going to happen as a result of performing the nursing interventions. the reason the related factors
(nanda term for cause or etiology of the patient's problem) become important to you in this process is that correction of them can also become goals as well.
the major part of the care plan is now completed, but it is the largest part. the last two steps, implementation and evaluation, take place after the care plan is written. the care plan is meant to be part of the cycle of care. it is implemented, or put into action. after a period of time, the patient is re-assessed to determine (evaluate) how effective the nursing interventions were. in other words, were goals met? goals and nursing interventions can then be re-written and re-adjusted based on this evaluation. and, the whole process starts over, except the major work has already been done way back in the early steps, at least for this patient.
and, that, in short, is how you write a care plan for one patient. you can see another example of how this is done at this thread on the general nursing student discussion forum: http://allnurses.com/forums/f50/need...se-223744.html
. there is also information on patient assessment and writing care plans on these threads:
good luck! something else that may help you with this is another form that i have a link to attached to my signature. that is the critical thinking flow sheet for nursing students.
welcome to allnurses!