Care plan.

i'm working on my first care plan and would like to know does the care plan involve an assessment, diagnosis, planning, interventions and evaluation (the nursing process)? or is just the diagnosis, intervention + rationale?

nb: we have been given a case study and the question asks us to develop a care plan that critically reviews the patients condition. in doing so, you are required to give the rationale on why you would implement the cited nursing interventions.

approach the case study sytematically. first you must have an accurate and comprehensive assessment. then start listing problems for this patient related to the illness/surgery/diagnosis, etc. the list may even include family issues that could negatively influence the patient. (only 1 example of many). now you must determine what intervention you can provide to positively affect this problem. your goal is to improve and/or resolve the problem. the careplan continues until discharge or death.

remember, this is a my very brief guide to a care plan. it does follow a logical order, however. you need to look at examples and structure your care plan to fit your patient.

the above site (in the #2 post) is a good example of how a care plan can work. do a search on this subject and you can find other threads regarding careplans, within this site.

good luck!!

siri, crnp, clnc, rlnc