Can anyone help me?

beth66335, BSN, RN · Nov 28, 2007

Hello,
I am in my first semester of nursing school (almost finished ). My problem is that I'm still rather confused about some things and I'm too embarrassed to ask my instructors because it seems like I should know these things by now. I feel very disorganized and confused most of the time and I can't seem to get a grasp of how to properly write a careplan. We are not allowed to use care plan books for references/rationales. We are only allowed to use "primary" sources. It is so frustrating because I spend way too much time doing these plans when I feel like I should be focusing on other things. It has gotten to the point where I can't even do my reading for theory or any other classes anymore, because ALL of my study time goes into these plans. I feel like I'm going to fail if this cycle continues any longer, especially with finals coming up . One thing that I don't understand is how a beginning student such as myself is supposed to know the time frames for my expected outcomes in my care plans. I have no idea where to find this kind of information. I understand that these goals should be specific to the patient, but I have NO IDEA what is considered realistic as far as timeframes are concerned. Also, I was under the impression that my careplans should include all the basic human needs in them (that was my own conclusion, I wasn't told that), but when I look up care plan examples in care plan books all they have listed are interventions that are directly related to the diagnosis. Am I wasting my time including too much unrelated (more holistic) info in my plans? If anyone has any answers I greatly appreciate it! I'm also freaking out because next semester we are supposed to write our patient plans in one evening the day before clinical and at this rate I'm afraid I won't be able to do it.

I'm not sure what you mean by primary sources, but I base my care plans on data from the pt chart and computer entries by the nurses. Where do you get your NANDA Dx? That source should be your rationale, and you pick a NANDA from your objective data in the chart or computer. Say for example you have an 85 yo female that only weighs 100lbs and has had hip surgery. Your Dx can be "Risk for Skin Integrity R/T hip surgery AEB age, poor skin score, immobility, etc. Also save all your previous CPs in a Word file. You can change your goals and interventions for new pts with similar Dx. My CI says we will use 80% of this stuff 80% of the time and if you have a preexisting CP to tweak, it will save time night before clinicals! Does this help?

Conrad283, BSN, RN · Nov 28, 2007

You say that you're not allowed to USE them, but are you allowed to reference them? If I were you, I'd go to Barnes and Noble, or a medical library and look into a careplan book to see how they're written and what you should be writing.

Daytonite, BSN, RN · Nov 28, 2007

ok, this is what you need to be doing. first of all, you should be following the nursing process when you do a care plan. step #1 assessment is probably the most important thing you have to do. you need to glean as much information about the patient as you can from their medical record and from doing your own physical assessment and talking with the patient. from that you need to develop a list of everything that is not normal. this list of abnormal assessment data becomes your patient's list of symptoms which you will see as their problems. that list/problems is what you use to determine your patient's nursing diagnoses. that is step #2 of the nursing process. once you have done that you move on to step #3 which is writing goals and nursing interventions. these are based almost solely on those symptoms the patient has (see the list you created from the patient's initial assessment and that you used to diagnose them). in essence, goals are pretty much the reversal of the symptoms. now, figuring out the time element that it will take to achieve that is a bit of a problem sometimes. that is information that comes with experience. something you will need to remember to do when you are in clinicals is to ask questions of the nurses. ask how long they have seen that certain things start to reverse when nurses start instituting some procedures. in some cases a pathophysiology book may be helpful, especially when it comes to things like healing. see post #157 on https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html for a discussion on what goes into a goal/outcome statement.

as for references, your instructors are looking for you to reference where you are getting your information regarding how long goals are going to take and where you getting your information regarding which nursing interventions to use. we also did this when i was going through my bsn program. every goal and nursing intervention had to be referenced. we used nursing textbooks, anatomy and physiology and pathophysiology books primarily for this. in some cases we even used a fundamentals of nursing textbook for basic nursing procedures. keep in mind that what we do is also based in the sciences so don't be afraid to go to other science resources (chemistry or biology) to support any claim that you are making. also, the time element on some goals will just be based on common sense. however, you cannot be afraid to ask other healthcare providers in the hospital setting about these things and ask if they have books or other resources in their department that you can look at to verify what they are saying. then get page numbers and book titles to quote in your references. you have to get over this fear of approaching and asking questions of others. your instructor is also a colleague.

you should also keep copies of all your care plans since many of the interventions, particularly with med/surg patients tend to come up again and again so you won't be wasting time re-looking up things. use your care plan books to help you with the rationales and goals, but use your textbooks to verify and use to reference these rationales since you are not allowed to use care plan books. some books, particularly nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig name and list the references for the interventions in their book. saunders comprehensive review for the nclex-rn examination, 3rd edition, by linda anne silvestri has a lot of the rationales for nursing interventions as well as some of the goals listed in it (use the index to find things). it is not a care plan book and i imagine could be used as a reference in lieu of a textbook or a care plan book for your care plans. other potential references would be medical dictionaries, lab and medication reference books and even internet websites. be creative. use anything that is going to support what you are using to rationalize statements you are making. i even referenced instructors statements from lectures when i was desperate.

greenfaery · Nov 28, 2007

Thanks you all for your help. I love the idea of buying a pathophysiology book!!! I can't believe I didn't think of that. I am also going to start recording lectures so that I can use that as a reference (didn't think of that either!) I am starting a word file that lists all the rationales for interventions that I have already researched, I think that will definately save me a lot of time.

Thank you thank you thank you!

Daytonite, BSN, RN · Nov 28, 2007

For pathophysiology try one of the books in the "Incredibly Easy" series, or I have a copy of

Pathophysiology: A 2-in-1 Reference for Nurses by Springhouse, Springhouse Publishing Company Staff which I think is very good. I will sometimes quote from it when answering questions for students on the forums. It includes nursing interventions as well as signs and symptoms for most of the major diseases and is organized by body systems. It costs 44.95.

greenfaery · Nov 29, 2007

For pathophysiology try one of the books in the "Incredibly Easy" series, or I have a copy of
Pathophysiology: A 2-in-1 Reference for Nurses by Springhouse, Springhouse Publishing Company Staff which I think is very good. I will sometimes quote from it when answering questions for students on the forums. It includes nursing interventions as well as signs and symptoms for most of the major diseases and is organized by body systems. It costs 44.95.

Thank you Daytonite, for all your help. I will ask my instructor about that book to make sure it's acceptable to her. I appreciate it!