Clan plan help

you must understand that a care plan is the documentation of your problem solving. you must follow the sequence of steps of the nursing process in writing a care plan. those steps are:

1. assessment (collect data from medical record, do a physical assessment of the patient, look up information about your patient's medical diseases/conditions)
   
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 diagnosis 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)

so, before you can do anything, you must gather all your assessment data. (see step #1).

please read my posts on these two threads that go into detail on how to write a care plan:

• https://allnurses.com/forums/f205/help-nursing-care-plans-277791.html
  
• https://allnurses.com/forums/f8/desparately-need-help-care-plan-279187.html

there is also information on care planning on these two sticky threads:

• https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum) - post #109 has the list of ackley/ladwig links to nursing diagnosis pages - psychosocial diagnoses are listed on post #145; wellness diagnoses are listed on post #84
  
• https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum) - how to write long goals is discussed on post #157
  

if you still are in need of help with getting your care plan started, please post a list of your patient's symptoms after going through your assessment data and i will help you with moving on to step #2 and #3.