care plans

becky0124. . .i help students on allnurses with care plan writing all the time. there are no free websites on the internet that i know of that do this. i have the time and i enjoy doing it. if you have specific questions when you are working on a care plan please post a thread on the nursing student assistance forum where i will see it. i respond to questions on that forum first.

you are not an idiot. i guarantee that there are others in your class who are also at a complete loss with writing a care plan and what gordon's functional health patterns are.

gordon's functional health patterns were developed by professor marjory gordon (a nurse and the first president of nanda--the north american nursing diagnosis association). they are a way to classify and organize information you are gathering during your assessment activities of a patient. assessment, you may recall from lectures, is the first step of the nursing process. the nursing process is a tool we use to problem solve. since a care plan is merely a listing of a patient's nursing problems, the nursing process is the best tool we have in putting a care plan together. it keeps us focused on the task and what we need to do at each step of the way. there are other ways to organize assessment (such as ros--review of systems--that doctors use in collecting health history and head-to-toe physical exams). however, your program specifically wants you to question patients and organize the data you collect using gordon's functional health patterns. you will do that with all the assignments you will turn in. [in my bsn program we were given a different set of guidelines and had to assess each of our patients according to this specific guideline we were given. it included a body system assessment and assessment of psychological, social, financial, spiritual and community factors. if we failed to do our assessment this way we lost huge points on our care plans.] there are websites that list suggested questions to ask for the 11 functional patterns on these websites:

• http://home.hiwaay.net/~theholt1/nurs1100/class5.htm - assessment guidelines
  
• http://gemini.utb.edu/nurs3606_84/box%206-1.pdf - a 2-page questionnaire from gordon, m. (1994). nursing diagnosis: process and application (3rd ed.). st. louis: mosby; gordon, m. (2000). manual of nursing diagnosis: 1995-1996. st. louis: mosby.
  
• http://wps.prenhall.com/wps/media/objects/3918/4012970/nursingtools/functionalhealthpatterns.pdf - functional health patterns with related nursing diagnoses
  

the reason assessment is so important is that it helps us identify abnormal data. when we are all functionally normally, we have no problems. do you agree? when we start to have problems, however, our clues are the little things we notice that aren't quite right. that is why we assess. yes, we hope the patient can tell us what is wrong, but also observe for those other things that "aren't quite right", those things that you are learning are abnormal about physical assessment. we are like detectives always looking for clues that point to a problem. the hard part, as you are about to discover, is what all these clues mean. diagnosing is not easy. it takes patience and experience to put the right clues with the right nursing diagnosis.

a good book for guidance in writing care plans is nursing care planning made incredibly easy. it shows how using the nursing process gets you to care planning and describes each step in detail. it comes with a cd that has care plans for med/surg, pediatrics, ob and psych conditions on it. if you have a copy of taber's cyclopedic medical dictionary you will find all kinds of information about the nursing diagnoses in the appendix.

also see the sticky thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

this is how i have adapted the nursing process to care planning and suggest that it be followed step by step in writing a care plan:

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
    

  [*]always sequence actual nursing problems before potential (risk for) or anticipated problems

  [*]use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance

  • http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs - maslow's hierarchy of needs
    

[*]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: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.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)