careplan HELP

when writing a care plan you need to follow the steps of the nursing process because it is a problem solving method. care planning is how we solve patient problems. the steps of the nursing process are:

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)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

the first thing you need to do is assemble all the assessment data you obtained on this patient. this includes the information you obtained from the chart. some time ago i did a list of what you need to obtain from the chart to help in assessing patients: https://allnurses.com/forums/2228927-post5.html. any physical exam information you have needs to be added as well. you are looking for abnormal data.

all problems have one thing in common--evidence that supports them. just like a detective looks for clues to prove that the murderer did the crime, the nurse must also find assessment data to support every nursing diagnosis we use. a nursing diagnosis is merely a shortened label for a much longer explanation of a problem. the nanda taxonomy (the grouping of the nursing diagnoses) includes the definitions of the nursing diagnoses as well as lists of their signs and symptoms (they are called defining characteristics). you can get the nanda taxonomy:

• 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
    

from what you posted, the patient:

• has a pharyngeal injury (? - needs more description)
  
• laceration of one of his wrists (needs more description)
  
• self-inflicted injury, but the patient said, "it got cut" (denial?)

what is going on with this pharyngeal injury? can he breathe? talk? eat? what does this laceration on the wrist look like? is the patient on any antibiotics? was the wound self-inflicted? was it a suicide attempt? what adls can and can't he do?

depending on how deep into the skin the laceration goes, the diagnosis likely to use is impaired skin integrity or impaired tissue integrity if the subcutaneous layer wasn't or was cut. risk for infection can be considered if infection is not already present in the laceration. when wounds are self inflicted the patient needs to be evaluated for the possibility of doing this to themselves again (risk for suicide) or evaluated for an accident of this sort occurring again (risk for injury).

i can't give you any more information without more information about the patient. your nursing interventions are based on treating the abnormal assessment data you found. for more on writing care plans, see https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing student discussion forum)