Careplan Help

this is assessment information. all care plans; all patient problem; solving begins with assessing the patient. part of the patient assessment includes collecting objective data from the patient's medical record. that would be the medications and test results. your summary of impressions sounds like the framework that your nursing program wants you to classify the information into. information from the chart isn't the only information you are collecting, is it? did you take care of this patient? if so, then you must have done a physical assessment of the patient. that is where physical, psychological, sociological, developmental and spiritual information gets collected. in my bsn program years ago we were to assess all our patients using a stress framework and were given specific assessment guidelines to do this. we had to discuss these specific stressors at the beginning of every care plan in the assessment section before we even got into the nursing diagnoses and nursing interventions. it sounds like you have to do something similar. so, i am betting that you have either had a course or lectures on how your nursing program wants you to do this and present it in a care plan. dig out your notes.

this thread gives a list of what information is important to look for in the chart: https://allnurses.com/forums/f205/help-preparing-clinical-day-227507.html

this is the crux of the nursing care plan. from the assessment information above you make a list of the patient's abnormal data--these are the patient's symptoms, or defining characteristics (nanda language for symptoms). every nursing diagnosis has a set of defining characteristics (or symptoms) and you need to match your patient's symptoms with appropriate nursing diagnoses. nurses base their nursing diagnoses on

• most importantly
  
  • 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)
    

  [*]data that they collect 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.

you will need a nursing diagnosis reference as well. 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.
  
• there are 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
    

you will need to put the nursing diagnoses in 3-part nursing diagnostic statements in the form:

short term goals (stg) and nursing interventions are based upon the patients symptoms.

this part of your care plan makes it the nursing school equivalent of a term paper.

there is information on how to write a care plan on this thread:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing discussion forum)