care plans

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I'am in a 1 year program to become an LVN. I need some help on how to do nursing care plans. The school does not provide a text book or a class. Basically, it is up to us to find out on how to make one. The instructors do not help alot either. Please I need help.

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Specializes in Med Surg, Ortho.

I'd start by going to buy a nursing care plan book.

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Yea, get a Nsg care-plan text book that lists NANDA approved nsg diagnoses. First you need to come up with a nsg diagnosis statement.

Match your pt's problems to one of the nsg dx's listed (e.g., acute pain for a pt. status post hip surgery or decreased cardiac output for a pt. w/heart failure...).

The next part is the "related to." This is where you put the cause of your pt's problem (nsg dx). This is the etiology of the nsg dx, the reason it's going on (e.g., tissue trauma secondary to surgery or a fall).

The last part is the "as evidenced by". This is where you put the signs and symptoms that let you know that you problem (nsg dx) is actually going on (e.g., pt. complains of pain; dependent edema; crackles).

So, in the end, you should come out with a 3-part statement:

Acute Pain related to tissue trauma secondary to surgery as evidenced by the patient's complaints of pain, facial grimacing, increased resp. rate.

Then also use your textbooks to find nsg interventions to help "fix" the nsg dx.

Set goals to measure whether or not your interventions worked. Be sure to include a specific time interval and a specific way to measure (e.g., pain rating scale). For example, "Pt. will state that pain is at an acceptable level [4/10 per pain scale] by end of shift."

Also, be sure not to use any medical diagnoses like congestive heart failure, hip fracture, or pneumonia.

Hope this helps, good luck!

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Specializes in LTC?Skilled and dialysis.

We did ALOT of care plans the first year of Nursing school...If there is anything I can do to help, lemme know.....the books are good tools....after u understand what is involved ( like not using medical dx)

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Specializes in med/surg, telemetry, IV therapy, mgmt.

there are currently 3 sticky threads on the student forums with information on how to write care plans:

one of the nicest books on the market on how to write care plans is

nursing care planning made incredibly easy published by lippincott williams & wilkins. it takes you through the care plan process via the nursing process. it comes with a cd that has 150+ med/surg, ob/neonatal, peds and psych care plans on it. it has care plans by medical disease or medical condition with nursing diagnoses and interventions. each care plan includes pathophysiology, complications of the disease, what you specifically want to look for when assessing the patient (this would be the abnormal assessment data, or symptoms, pertaining specifically to that disease) and any diagnostic tests that are usually done. the care plans also include outcomes (goals).

i check the nursing student forums daily for care plan questions and answer the ones in the nursing student assistance forum first. all care planning begins with the assessment you do of the patient. because a care plan focuses on the nursing problems that a patient has, you are specifically going to want to be alert for the things that are not normal. nursing assessment includes:

  • 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.

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Specializes in Med Surg, Ortho.
I'am in a 1 year program to become an LVN. I need some help on how to do nursing care plans. The school does not provide a text book or a class. Basically, it is up to us to find out on how to make one. The instructors do not help alot either. Please I need help.

What kind of school does not provide text books or class??? This doesn't sound right....do they not even recommend books for you to buy??? Just sounds scary that you're getting your nursing education from a school like this.:imbar

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