Care Plan Case Study Samples

CP2013 · Oct 23, 2012

I am trying to find some resources online for sample case studies that I can use to practice doing care plans, but have had no success with google search. I have to do my first actual care plan on a patient in clinicals this coming Saturday and I really want to get some practice writing them. Any help is greatly appreciated! :)

Has your school presented an example? Have they suggested care plan books?

My text books have the components of the care plan in the literature, so I just use that information and put it into the format the school wants and in my own words.

Mrs.Priss · Oct 23, 2012

we have gotten one example but there arent any in the text and we werent required to get a care plan book, only a nursing dx book or cards. I have ordered a care plan book, though! I havent been able to find any samples. i have to do one Saturday on an elderly immobile patient and just wanted to find one similar to practice and look up information. I may just try to do a mock one on my pt. Thank you! :)

CP2013 · Oct 23, 2012

we have gotten one example but there arent any in the text and we werent required to get a care plan book, only a nursing dx book or cards. I have ordered a care plan book, though! I havent been able to find any samples. i have to do one Saturday on an elderly immobile patient and just wanted to find one similar to practice and look up information. I may just try to do a mock one on my pt. Thank you! :)

I use a diagnosis book usually. We do a format of basically:

Patient demos (age,gender)

Admitting diagnosis

Nursing Diagnosis #1

Patient centered Goal/outcome statement *needs to be measurable (ie, by time of discharge, before lunch, by end of shift, etc)

Interventions (how you will reach the goal)

Evaluation (did you meet goal? Why or why not? How would you modify goal statement)

Repeat for nursing diagnosis 2-5.

I do typically 5 nursing diagnoses for my care plans. I like to make sure I voter everything.

I just do it handwritten on notebook paper for clinical and type it up when I need to submit it for grading. My school also provides a standard form with the information they are looking for. We need to include assessment data prior to our diagnosis.

Hope this helps.

Enthused RN, BSN, RN · Oct 23, 2012

Here's an example of part of one of my care plans, it's a bit simplistic (my interventions can be more specific i.e. monitor respiratory rate, depth, and ease of respiration q 1 hour, etc, I'm too lazy to edit it right now). Maybe you can use this format. I use the Nursing Diagnosis Handbook by Ackley; but I access the Elsevier website.

[TABLE=width: 106%]

[TR]

[TD]Date of Patient Care

[/TD]

[TD]Patient Problem

(stated as NANDA diagnosis)

[/TD]

[TD]Expected Outcomes

(outcomes appropriate and measurable)

[/TD]

[TD]Nursing Interventions and Rationales

[/TD]

[TD]Evaluation of Patient Response

[/TD]

[/TR]

[TR]

[TD]XXX

[/TD]

[TD]NANDA : Ineffective breathing pattern r/t loss of functioning lung and ventilation-perfusion imbalance AMB abnormal skin color, low Sp02, shortness of breath, coorifice rhonchi, and altered mental state

Subjective (as evidenced/ manifested by data): Altered mental status, shortness of breath

Objective (as evidenced/ manifested by data): Abnormal skin color, low Sp02 reading, coorifice rhonchi

[/TD]

[TD]Patient will demonstrate a breathing pattern that supports blood gas results within his normal parameters by end of shift.

[/TD]

[TD]1. Monitor respiratory rate, depth, and ease of respiration.

Rationale: Continually assessing patient’s breathing status will alert the nurse to any deviations from his normal baseline.

2. Auscultate breath sounds every 1-2 hours.

Rationale: Frequent auscultation will alert the nurse to any changes in his conditions.

3. Monitor oxygen saturation continuously using pulse oximetry.

Rationale: Continuous pulse oximetry monitoring will alert the nurse of any changes in patient’s condition even when he/she is not even in the room.

4. Provide supplemental oxygen as ordered by provider.

Rationale: Supplemental oxygen will help maintain Sp02 within normal parameters.

5. Keep head of bead raised at least 30 degrees at all times.

Rationale: When patient is laid flat, his lungs are not able to expand as much compared to when he is sitting up more. In addition, pulmonary congestion is increased when patient lies flat so he may experience greater dyspnea.

[/TD]

[TD]Met – Patient’s Sp02 was maintained at > 95% throughout the shift. Coorifice rhonchi was still present in all lobes of the lungs; however patient did not display any exacerbation of his condition.

[/TD]

[/TR]

[/TABLE]

leqwedz · Apr 7, 2014

thank you taking your time to post this.so much help.thank you again.