Care Plans HELP!!!

hi, jenny!

a care plan, as simply as i can state it, is a determination of the patient's nursing problems and strategies to fix them. it is problem solving. to help us with problem solving we have a tool called the nursing process to help us. the nursing process keeps us focused and thinking in a rational manner. nurses are not the only profession to use this kind of rational process. other professions that use a similar rational approach to problem solving are medicine, architects, police (crime) solving, plumbers, car mechanics, and many more. here is an example of how the nursing process works when applied to a common everyday example:

the best way to approach the writing of a care plan (especially as a student) is to utilize the nursing process. this is how i suggest you can do that:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]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 diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

care plan books are fine, but use them as supplements and for suggestions. by using the nursing process you will customize every care plan to each patient's needs. if you have a copy of nursing diagnosis handbook: a guide to planning care by betty j. ackley and gail b. ladwig or know someone who does, read or get a copy of the few pages in section i of the book where the authors explain how the nursing process is used to write a care plan. nursing care planning made incredibly easy also uses that same approach in the way the book is organized.

what i find (i answer a lot of care plan questions) is that the biggest problems for most students is

• their assessments are not thorough enough - this is because they do not know enough about the pathophysiology, signs/symptoms, medical treatment and complications associated with the medical disease(s) or condition(s) the patient has
  
• they frequently get stuck with how to go about choosing nursing diagnoses - because they just didn't get enough data or they missed noticing data when they did their assessment

doctors and police detectives must diagnose as well. diagnosing requires a logical approach to problem solving. to diagnose you must break down the information you obtain from a patient's medical history, physical examination, and laboratory test results and then reassemble it into a pattern that fits a well-defined classification we call a nursing diagnosis. every nursing diagnosis has a definition, a set of defined characteristics and some related factors that you can refer to in helping you make a diagnosis. nursing diagnosis is not guesswork. it is rational decision-making. you will be surprised to find that you may already have this nursing diagnosis information if you have a copy of taber's cyclopedic medical dictionary.

actual problems are situations that already exist and their treatment always comes first; potential problems are situations that could happen so there is only treatment to prevent them from coming to fruition (occurring), so they are not considered as important compared to an actual existing problem. actual problems will be diagnosed with a positive diagnostic label (i.e., decreased cardiac output, impaired physical mobility). potential problems will be diagnosed with a label indicating there is a chance that the problem could occur (i.e., risk for injury, risk for deficient fluid volume). there is also a difference in the way interventions are carried out for these two different types of situations. with actual problems you are developing strategies (nursing interventions) to affect some kind of change (improvement, stabilization or support the deterioration) in the problem. with potential problems you are developing strategies to prevent an actual problem from occurring.

if you have a little old patient who has the potential to get bedsores because they won't stay turned on their sides, has a poor nutritional state and is pretty much skin and bones, you might diagnose risk for impaired skin integrity because you are concerned the patient could get a decubitus on their coccyx. that is a potential problem for this patient for the reasons stated. you will intervene and have interventions designed to try to prevent the skin from breaking down. however, the minute the skin on their coccyx stays reddened even with massage or the surface skin is lost, skin breakdown is no longer a potential--it is an actual problem--and is now impaired skin integrity. you will have interventions that are designed to improve the broken skin and promote its healing.

these sticky threads on the student forums have care plan information on them:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans
  
  • https://allnurses.com/forums/2751313-post8.html - "risk for" diagnoses (anticipated problems) post #8.
    

  [*]https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans

  • post #109 has the list of ackley/ladwig links to nursing diagnosis pages
    
  • psychosocial diagnoses are listed on post #146
    
  • wellness diagnoses are listed on post #85
    

  [*]https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb)

  • (https://allnurses.com/forums/2509305-post158.html) - how to write goals is discussed on post #158
    

  [*]https://allnurses.com/forums/f50/care-plans-finding-nsg-articles-2-really-good-websites-everyone-should-know-about-125098.html - care plans + finding nsg articles: 2 really good websites everyone should know about!