Beginning Care Plans

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Hi. I know this is going to sound silly, but I am having such a tough time with Care Planning. We've just started the class, but already have an assignment due. Does anyone have a way to make CP more easily understood? Thanks in advance for your help! J

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What exactly are you having trouble with? Is it the nursing diagnoses, or organizing the map so it doesn't look like a plate of spaghetti, or linkages? I don't know what to say to help, because I'm not sure what you're struggling with.

They do get easier, though. I pulled an all-nighter with my first care plan because it was just so hard, but I can finish them in a couple of hours now. It just takes practice, and they really do get easier.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

hi, jennifer9701, and welcome to allnurses! :welcome:

yes, i have been working at trying to simplify the teaching of the nursing care process for the last two years. you can see my many posts on allnurses all over this and the nursing student assistance forum. what is your first assignment? perhaps i can help you with it.

there is a book called nursing care planning made incredible easy which you might find helpful. i don't particular like the nursing diagnosis section of it because i don't think it explains that area very well and that is something that students question time and time again on the forums.

i can tell you that overall that a nursing care plan is a written documentation of the nursing process. the nursing process is nothing more than a problem solving method. it consists of 5 steps:

  1. assessment (collect data from medical record and by doing a physical assessment of the patient)
  2. 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 diagnosis to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

in actuality you and i have been using this method all our lives to solve little crises and problems that come up in our lives. let me give you an analogy that you can relate this to:

you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).

what nursing has done is to take that process, break it down into five steps (they actually extrapolated them from the "scientific process" used in the various sciences), and given us some very specific rules and nursing information that we have to follow when performing each of those steps. the difference between a flat tire and a patient with problems is that the patient usually has a bunch of problems that you have to juggle at one time. a flat tire is just one thing to worry about. so, a care plan for a patient with more than one problem can get a little complicated. therefore, you have to be somewhat organized in how you put the care plan together.

i check this and the nursing student assistance forum daily for care plan or nursing diagnosis questions by students. don't hesitate to ask if you have a question. this stuff can be extremely confusing when you are first learning it. like any skill, it takes practice and learning from mistakes you make in attempting to learn it. it will take many, many care plans to become good at writing them.

also, part of doing them is to learn more about a patient's disease condition. you must know what is going on with a patient's medical disease, how the doctors diagnose and treat it because it affects how we go about carrying out the doctor's orders and assessing the patients.

there are many helpful sticky threads on allnurses that are going to be of value to you as you write care plans. there are two threads in particular on the student forums about care planning you might want to read through that have some good information on them:

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