Doing Nursing Care Plans

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Hello

Today we talked about doing nursing care plans but the teacher was not the best at teaching this rather challenging material for first semester students. Does anyone have suggestions on a website to go to for this. I don't have a book yet on it.

Thank you.

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I don't know of any websites but you really should get a care plan book. You will use it all the time in your first semester. My care plan book saved my soul last semester.

No care plan book = Pulling your hair out as you run from the classroom

Having a care plan book = Sitting back in your chair as you breathe a big sigh of relief.

At least that is how it was for me!! Good luck!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

no websites for this. we have several sticky threads that have attempted to help students writing care plans and i will list them for you. i check this and the nursing student assistance forum daily for care plan questions and answer them.

care plans are written by following the steps of the nursing process in the sequence that they occur:

  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)
    • 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) with the disease
    • data collected 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.

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]how to write goal statements: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

one of the better books you can buy (i know you were asking for websites) on how to write care plans is nursing care planning made incredibly easy. the book comes with a cd that has care plans for med/surg, peds/ob and psych conditions. the book is organized by the nursing process as well. everything for care planning begins with assessing the patient. it is what we find that is abnormal that we end up treating, or doing something about. we nurse wounds (wounds are abnormal). we help people walk (not being able to walk without maintaining our balance is not considered normal). we give bed baths (not being able to wash ourselves because we are too weak is considered an abnormal symptom). these are all things we find from assessing the patient. from those assessments we determine what problem exists: can't move, has pain, has broken skin, etc. then, we can plan the action we take to do something about these problems: dress the wounds, get help with walking (canes, walkers, physical therapy), give pain medication.

the nursing process is problem solving and that is what we do. a care plan is the written documentation of that problem solving. you have actually done this process many times in your life. you are only now being told it has a name and being given specific details of what needs to be done for it to comply with nursing standards. here is a real life example of how the nursing process (problem solving) works in a real life situation:

you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).

the nursing process, care planning. very rational, very detail oriented. when you are ready to do one and if you have questions post a thread and i will help you through it. writing care plans is a skill like any other skill in nursing. after you get a few under your belt it gets easier to do. the first ones will be laborious, but you learn so much from each one you do.

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