What semester are you? Is this a real patient? Care maps are just like care plans but in a different layout/format.
Welcome to an!!!!! Concept mapping
a great resource on care maps step by step.
The biggest thing about a care plan/map is the assessment. 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
A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.
- 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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. At all times. And that is within the spirit of step #1 of this whole 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. 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.
care plan reality: is actually a shorthand label for the patient problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every NANDA nursing diagnosis has a definition). [thanks daytonite]
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.
What is bradycardia? What happens with bradycardia? What can happen to a patient with Bradycardia?
Admitted for hardware failure with a secondary Dx of bradycardia. prev illness of chronic kidney disease, diabetes type 2, hypertension, anxiety, depression, schizophrenia, paroxysmal tachycardia.
This gives my what the patient has....now what do you need to look at for what the patient needs. Tell me about your patient. What care plan book do you use?