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Careplan Help

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by puffy1 puffy1 (New) New

I have to write a care plan for one of my patients. This is my first time and I really don't know what to look for. I have to go to the Medical Record department of the hospital to look at their medical record history.

I am not really sure what I am to look for.

The things needed on my lists are:

Part I

A. Summary of Impressions (2)

B. Client Variables (overall depth and breath of information)

1. Physical (complete and attached (1)

2. Psychological (1)

3. Sociocultural (1)

4. Developmental (2)

5. Spiritual

C. Client Stressors (3)

(multiple stressors I.D. and discussed)

D. Medications (3)

Complete info. (classification/rationale/Nursing implications/effects on labs. Includes references.

E. Diagnostic Tests (3)

Complete info with references.

I.D. reason that pt. lab results are abnormal by underlining cause.

I.D. labs that should be ordered and states rationale.

F. Medical Diagnosis/Surgical Procedures (3)

Must be referenced. Includes Pathophysiologic template.

Part II Focus sheets

A. Nursing Diagnosis (5)

Appropriateness of diagnosis.

All S&S and R/F somewhere in care plan.

B. STG/OC (5)

Are OC measurable, specific, observable.

C. Interventions (5)

Treating the etiology

Each OC addressed.

I.D. primary, secondary, tertiary interventions.

D. Rational (5)

Each intervention has a related rational and each rational is

referenced.

E. Evaluation (5)

Part III References (3)

Part IV Overall Quality of Paper (2)

Spelling, punctuation, attention to detail, organization, APA format.

I know this is alot but can you offer any advice? Thanks soooo much!!

i have to write a care plan for one of my patients. this is my first time and i really don't know what to look for. i have to go to the medical record department of the hospital to look at their medical record history.

i am not really sure what i am to look for.

the things needed on my lists are:

part i

a. summary of impressions (2)

b. client variables (overall depth and breath of information)

1. physical (complete and attached (1)

2. psychological (1)

3. sociocultural (1)

4. developmental (2)

5. spiritual

c. client stressors (3)

(multiple stressors i.d. and discussed)

d. medications (3)

complete info. (classification/rationale/nursing implications/effects on labs. includes references.

e. diagnostic tests (3)

complete info with references.

i.d. reason that pt. lab results are abnormal by underlining cause.

i.d. labs that should be ordered and states rationale.

f. medical diagnosis/surgical procedures (3)

must be referenced. includes pathophysiologic template.

part ii focus sheets

a. nursing diagnosis (5)

appropriateness of diagnosis.

all s&s and r/f somewhere in care plan.

b. stg/oc (5)

are oc measurable, specific, observable.

c. interventions (5)

treating the etiology

each oc addressed.

i.d. primary, secondary, tertiary interventions.

d. rational (5)

each intervention has a related rational and each rational is

referenced.

e. evaluation (5)

part iii references (3)

part iv overall quality of paper (2)

spelling, punctuation, attention to detail, organization, apa format.

i know this is alot but can you offer any advice? thanks soooo much!!

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

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

part i

a. summary of impressions (2)

b. client variables (overall depth and breath of information)

1. physical (complete and attached (1)

2. psychological (1)

3. sociocultural (1)

4. developmental (2)

5. spiritual

c. client stressors (3)

(multiple stressors i.d. and discussed)

d. medications (3)

complete info. (classification/rationale/nursing implications/effects on labs. includes references.

e. diagnostic tests (3)

complete info with references.

i.d. reason that pt. lab results are abnormal by underlining cause.

i.d. labs that should be ordered and states rationale.

f. medical diagnosis/surgical procedures (3)

must be referenced. includes pathophysiologic template.

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.

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

nursing diagnosis related to related factor, or etiology (r/f) as evidenced by signs and symptoms, or defining characteristics (s&s)

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

part ii focus sheets

a. nursing diagnosis (5)

appropriateness of diagnosis.

all s&s and r/f somewhere in care plan.

b. stg/oc (5)

are oc measurable, specific, observable.

c. interventions (5)

treating the etiology

each oc addressed.

i.d. primary, secondary, tertiary interventions.

d. rational (5)

each intervention has a related rational and each rational is

referenced.

e. evaluation (5)

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

part iii references (3)

part iv overall quality of paper (2)

spelling, punctuation, attention to detail, organization, apa format.

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

kay... i learned something today..am just reading articles here.. thanks DAYTONITE..

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