Care Plans

nurseprnRN, BSN, RN · Nov 1, 2013

There's no substitute for developing your own. There is no such thing as a cookie-cutter plan, or even a cut-and-pastable template. Get yourself the books, read the material, and you'll be much more successful at it.

There are several threads here on care planning-- there are ALWAYS threads here on care planning-- so read them all and see what you can learn!

danceyrun · Nov 1, 2013

Check your med-surg textbook, many times there are care maps/care plans in there. Absolutely do your own work, but if you are having trouble understanding what they are and how they work, try that. Also the nursing diagnosis handbook by ackley will serve you wonders throughout nursing school.

lwhatley · Nov 16, 2013

Ugh, I typed out a beautiful lengthy comment leading up to the two examples I'm about to link out to, but while I was attempting to attach those examples, I hit a wrong button and it completely deleted my text. So bleh.

To summarize the ideas of that now giant waste of type-time, I'll just highlight the bullet points.

- While I admire you're initiative to develop the skill, the actual practice of organically developing a care plan complete with APA formattng and detailed rationale is becoming more and more something you'll only do in nursing school. (I am in no way downplaying the importance of developing the skill to do this though, I'm just saying that you shouldn't stress about perfecting the process because clinical application in your career beyond having an understanding of appropriate nursing diagnoses and the dx's treatment implications will become irrelevant)

- This transition to irrelevancy is related to the introduction of electronic charting applications that include IPOC's (individualized plan of care). It's turned the entire traditional process of writing up a care plan (Nurse Dx-->Goal/outcome Identification-->interventions to reach goal-->rationale behind intervention-->criteria to evaluate completion of goal) into a simple task involving selecting from a populated list of problems. Those problems have predesigned automated plans of care based on current standards of practice associated with them that becomes attached to their chart for the entire health care team to add to, assess, or modify. It's actually pretty effing sweet.

- I've helped a lot of nursing students with developing their care plans and while doing so have learned that the expectations of what to include in a care plan vary by both institution and professor. With that being said, I'm posting two examples of my own care plans from nursing school that were technically considered two different types; a standard care plan, and an extended care plan. The only difference between the two is that the extended care plan required a citation for every intervention/rationale included to prove it was supported by relevant evidence based practice.

It's not to say that my standard care plans' interventions/rationales didn't require EBP support, it's just that I didn't have to specifically cite it (assuming I didn't directly quote a source). It was just assumed that I had basic understanding of the most recent EBP and could produce supporting literature if ever questioned to do so. (The standard care plan was incredibly less difficult for obvious reasons, but the procedure is still the same)

Here's a link to the standard (it includes 2 Nursing Dx's, one r/t pathophysiology, the other r/t psychosocial):

https://drive.google.com/file/d/0BzP_7cm_N-yaRDVaZ1lGQl9YWXc/edit?usp=sharing

Here's the link to the extended care plan, subject: Risk for injury r/t blood transfusion

(it's a quick copy/paste of 10 pages from a 50 page paper I did for my OB clinical, which is why it doesn't have the APA required headers and page numbers included, but those elements are formatting stuff I would hope you could figure out on your own in the event you use this as a guide to creating your own):

https://drive.google.com/file/d/0BzP_7cm_N-yaTjl3T0JYQkNic28/edit?usp=sharing

If you have any other questions, please don't be scared to ask, I remember how frustrating care plans were to get the hang out back when I was first learning how to create them in a logical sequence. As for the best references to use, googling for examples of care plans is always a solid start, but I always turned to my E.A. Davis pocket guide before hunting down anything else...it was always a solid start to the process, I'd definitely recommend you pick one up.

I posted on another thread on here actually breaking down the process I use to brain storm and write the Dx's and lead into developing the care plan, but I'd have to hunt down the link...maybe I'll add it to an edit for you to look back on if you'd like. It's long winded like this comment though, so you've been warned haha.

Esme12, ASN, BSN, RN · Nov 16, 2013

Hi All!
I'm a first semester nursing student, and like any other program, we're doing care plans! In my program, I feel like they're not pushing us as much as they could be on the care plans, and my clinical instructor is really relaxed about them. (She's the one who grades them!) I understand that in the future, I'll continue to be expected to make quality care plans, and I'd rather get myself up to par now, rather then letting the poo hit the fan!
In that regard, I was wondering if anyone could post or send me a good care plan to use as a reference! Something with good APA formatting, and rationales for the interventions! I think I need to use much more descriptive language in my care plans, and I want to see something similar to that! Perhaps a care plan on pain or a psychosocial diagnosis like anxiety?
Any good resources out there? Something free on the internet? Thanks!

Welcome to AN!

The largest online nursing community!

There are good resources out there....what care plan book do you have? Do you have the NANDA I book for a resource? Many schools have their own format they require you to use.

Care plans are all about your patient assessment which need to be individualized for every patient. A good care plan book can give you nursing interventions with references....APA style.

Here is an example of a care pan with APA format for pain....Acute Pain, Irritated Mucosa from Acid Secretions