Care Plan Confusion

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Hello. I am currently working on my first care plan. I originally thought that I had a basic understanding of how to create my diagnoses. Our format for school though is super weird though. It is separated into three columns: First column is for NANDA diagnosis. I understand that. Second is for supporting Pt data (relevant symptoms/defining characteristics/specific data gathered from assessment), instructor told us to put the related to part here (this seems to be the AEB part to me). The last column is for Dynamics (defining characteristics from med-surge book; supports this as a problem). We were told to look for signs and symptoms from another source that supports out diagnosis. How do we even do that. I have been confused since Thursday and I tried to get clarification from our instructor, but it was hectic during post conference due to the next group coming in. I was under the impression that our diagnosis was to be assessment driven. What does the patient's symptoms tell us, that leads to the diagnosis. I don't understand how to use another source to support our diagnosis? If anyone has any ideas and would like to share how to attack this I would greatly appreciate it. Thanks.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

You use Google...you go to the library. YOu look it up.

For example....DKA diabetic ketoacidosis you do a search and get results......https://www.google.com/search?q=DKA&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a

A favorite of mine is medscape and it is free.....http://emedicine.medscape.com/article/118361-overview and

Nurses - Medscape

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This format is just not what I thought it would be. Hopefully I will receive some feedback as to what I am doing from my instructor. Thank you for responding and for providing a reference.

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Nursing diagnoses r/t causative factor AEB s/s and characteristics presented by patient

See if that way helps better and suits criteria.

Here's an example I have used: Hypoxemia r/t decreased perfusion at thealveolar capillary membrane AEB decreased Hgb and Hct, and pt c/o weakness andfatigue

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
This format is just not what I thought it would be. Hopefully I will receive some feedback as to what I am doing from my instructor. Thank you for responding and for providing a reference.

You use your APA format to quote your sources

Try these examples

Nursing Resources - Care Plans

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Nursing diagnoses r/t causative factor AEB s/s and characteristics presented by patient

See if that way helps better and suits criteria.

Here's an example I have used: Hypoxemia r/t decreased perfusion at thealveolar capillary membrane AEB decreased Hgb and Hct, and pt c/o weakness andfatigue

That's what I was planning on doing, but we are suppose to cite symptoms from our text. That's the part that didn't make sense. On the form there is no place to list our pts signs and symptoms. It's just weird. I did use Esme's suggested research sites and in my own way relate it back to my pt. thank you for the response =)

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You use your APA format to quote your sources

Try these examples

Nursing Resources - Care Plans

Thank you so much for this resource. It is beyond helpful. Still feeling a little shaky but not so stressed. I appreciate all you do to help us students.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

anytime....((HUGS))

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