care plan!!!

hi, magners, and welcome to allnurses!

all the information in care plans (nursing diagnoses, goals and nursing interventions) are based upon a patient's specific symptoms, not their medical diagnoses. so, i really can't help you very much without knowing what your patient's symptoms are. you must also follow the steps of the nursing process in the sequence in which they occur:

1. 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)
   
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)

step #1, assessment is the most important step. from assessment you find out what the patient's symptoms are. in step #2 you make a list of the patient's symptoms. it is that list of symptoms that is important in the remainder of the writing of the care plan.

here are two recent threads where i discussed how to write a care plan:

• https://allnurses.com/forums/f205/help-nursing-care-plans-277791.html
  
• https://allnurses.com/forums/f8/desparately-need-help-care-plan-279187.html
  

you will also find care plan information on these two sticky threads:

• https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)
  
• https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)
  

if you will post a list of your patient's signs and symptoms i can give you more help, but with only a list of medical diagnoses, it is nearly impossible to help you out because it doesn't tell me anything about this patient.