Careplan help

  1. Hi,

    This would be to anyone that knows how to write a care plan. This is my first time writing one and I don't know what the heck to do. I have a general idea and would need some help getting started. We have to list the nursing diagnosis with supporting data, client goal, interventions, and the scientific rationale for interventions. We have not gotten to the implementation and evaluatuion phase yet. So if you think that you may be willing to help this ADN student out please email me soon as possible at Any and all input will be greatly appreciated. Thanks
  2. Visit justbegun profile page

    About justbegun

    Joined: Jul '01; Posts: 18
    I am currently between jobs until Ican get situated with school


  3. by   hoolahan
    Hi JB,
    Listen, teaching someone how to write a care plan is, for me anyway, way too much typing for a post or an e-mail. Go to your school's library or call your local hospitals and ask the medical librarian if they have a copy of Carpenito's Nursing Diagnosis book. The first 12 pages or so gives a really good explanation of what to do.

    The nursing diagnosis is the tricky part. Here is a BRIEF example

    Problem: Alteration in skin integrity
    Etiology: related to bedbound status
    Symptom: as evidenced by stage ii breakdown on sacrum
    (Nsg dx must have these 3 components prob, etiol, & Sympt, ...usually)

    Goal: Wound will be decreased in size by three weeks and healed in nine weeks (goals need time limits, must be measureable)

    Outcome: Client's wound will be healed and wound will remain free of infection. No new breakdowns.(What you want the end result to be)

    Nursing orders: (how you plan to reach your goals and outcomes)
    1. Assess nutrition, ie 3 day diary, skin turgor, quantities of fruits veg's PROTIEN, milk etc, instruct in balancing diet and ways to inc prot in diet if not contraindicated (liver disease)
    2. Turn pt q 2 hours, teach caregivers to avoid prolonged pressure on bony prominences
    3. Measure wound weekly. If no improvement in wound after 3 weeks of present wound care, consult physician or wound care consultant.
    4. Observe for and report signs of infection.
    blah blah blah etc etc etc yada yada yada

    Also, the student nurse forum is pretty active here, so check it out, they are recent pros at writing care plans.

    Good luck.
  4. by   nilepoc
    Do what I did,

    get the mosby cards on care plans, and liberally apply what they have to offer to your care plan.

    You don't have to reinvent the wheel, when it comes to care plans.

    good luck