CPNE...Care plan practice?

i look for and answer most of the care plan questions (that i can find) on the allnurses forums. i've written care plans for years, but it really didn't prepare me for what the nursing schools are really teaching.

what i have learned in helping students is that care plans are really a written documentation of the nursing process. the nursing process has five steps and as long as you follow those five steps, in sequence, your care plan should fall into place nicely. the nursing process is nothing more than a problem solving method--period, end of story. and, that is what rns do on the job--solve problems all day long. just about every profession has to do some kind of problem solving. we problem solve situations every day of our lives and use the same process that nursing wants us to use. the difference is that nursing has given it a fancy name and expanded on what we need to do in each of the steps.

one of the best books i think you can have to help with care planning is nursing care planning made incredibly easy. i have this book. i am always searching for ways to explain care planning in easier terms. many nursing instructors make it so dog gone difficult when it really isn't. part of the problem is that they don't use simple language and insist on continuing to use a bunch of gobbledygook terms that they can't clearly explain so students can understand them. this book comes pretty close to making it a lot easier.

nursing diagnosis is nothing more than a newer concept that came about in the 70s. prior to that we just had "problems" that we determined after doing an assessment of a patient. a nursing diagnosis is nothing more than a canned "label" that we now put on a problem. nanda-i (north american nursing diagnosis association, international) has very nicely worked to years for develop, and publish, a taxonomy (a list of the nursing diagnoses) that includes for each

• a definition
  
• signs and symptoms (they call them defining characteristics)
  
• etiology of the signs and symptoms (they call them related factors--this is your pathophysiology link)

the gurus over at nanda actually research and work with these diagnoses to get the right wording and terminology for each of these diagnoses. they do it for us who use them so we don't have to sit around scratching our heads trying to figure out what to put down on a piece of paper, or worry over whether we've diagnosed someone correctly or not. they have published all this work in a very inexpensive reference that sells for $24.95 called nanda-i nursing diagnoses: definitions & classification 2007-2008. care plan and nursing diagnosis book authors have to pay nanda a royalty to use this information and re-print it in their books. these commercial books have the added features of nursing interventions and goals among other things that are added to them. some have care plans by medical diagnosis, not a good way to present care plans in my estimation because we treat the patient's response to their illness, not their medical condition. one of the biggest confusions i find among nursing students is the one between medical diagnosis and nursing diagnosis. the two are not the same although the process to get to each of them is basically the same. there are two other books that just have goals and nursing interventions listed in them. nanda has approved them and incorporated them with their nursing diagnoses. they are nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson and meridean and nursing interventions classification (nic), by joanne mccloskey mccloskey dochterman, gloria m. bulechek, gloria m. bulechek. you will also find commercial care plan and nursing diagnosis books paying royalties to these authors to use their work in their publications.

there are websites where you can see examples of care plans that have been done by students. the links are listed somewhere on the posts of either of these two threads on the student forums:

• https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)
  
• 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)
  

i am aware that you students who are in online programs do a specialized care plan seminar. however, if you have any problems i am usually available and willing to help out. the place to post a care plan question is on either the nursing student assistance forum or the general nursing student discussion forum.

as with learning any skill, and care plan writing is a skill, you start slow, may make a few errors, learn from your errrors, but practice makes perfect. and, the reason it is a focus of all nursing programs is because (1) it is a good reflection of how to think critically when solving a problem, and (2) care plans are required to be in every acute hospital and long term facility patient medical record when those facilities accept federal medicare or medicaid reimbursements. this is by federal law (title 42).

As long as I am at home and able to get to my computer and not hospitalized I will answer them.