Care Plans

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Anyone know of good websites to get examples and help? TIA

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

it is very difficult to find examples of a really good care plan because of plagiarism and patient confidentiality. what is on the internet are examples that have been posted to give you a taste of what a care plan is.

individualized help for your care plan can be found on allnurses by posting questions on this forum, the nursing student assistance forum or the general nursing student discussion forum. i answer most all questions pertaining to care plans asked on these forums. you can find specific subjects by using the advanced search and search using my screen name and key words like "diagnosis" or a medical diagnosis. there are several sticky threads specifically for care plan questions. the newest one is in the general nursing student discussion forum:

the older ones are:

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Specializes in Coronary Rehab Unit.

Have mentioned before, shall mention again ..... Daytonite, you are such an exTREMELY valuable asset to this community.

Thanks so much !!! (again !!! :cool: )

- Bylon

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I agree! Thanks!!!

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

you can look at examples all day long, but it is nothing next to actually doing one. there is a lot of mental work and thinking that goes into the construction of a care plan--more than shows when you look at one on paper. it's like watching someone ride a bike or drive a car. you can say to yourself, "i can do that!" but when you actually get on the bike or sit behind the wheel of a car for the very first time it is quite a different story, isn't it?

when you are ready to work on your first care plan, i can help you out. i recommend that you follow the steps of the nursing process. the assessment is the most important step because that is where you get all the information that ultimately ends up contributing to the care plan. you need to get as much information not only from the patient, but from their chart as well (see https://allnurses.com/forums/2228927-post5.html)

  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.

[*]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.

[*]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

    [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

    [*]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)

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I need help with a general practice care plans for example a stroke:madface:

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