care plan help

  1. Hi. I'm new here. I need care plan help!!!!!!!! I hate care plans! Any good sites? Thanks
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    About missiongirl

    Joined: Aug '06; Posts: 2
    dental assistant
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    7 Comments

  3. by   suebird3
    Welcome to allnurses.com! I moved your post to a more appropriate Forum; you should find some help here. There are several useful "Stickies" at the top of the Forum.

    Suebird
  4. by   RebeccaJeanRN
    Don't know of good sites, but do know of some good reference sources: All-in-one Care Planning (large paperback book), plus many sections of your Med-Surg and Pediatric books show common diseases, nursing diagnoses and interventions (you'd be amazed when you really look in them, just as I was! LOL) Further on, for Critical Care, I used a small book called Manual of Critical Care Nursing, which was great for Diagnoses and Interventions. Also, my very first text, Fundamentals, had a pull out sheet that listed all currently accepted nursing diagnoses. For the Pathophysiology part, I used my Patho text (weird that I never used it for Patho, but I used it many times for Care Plans). Lastly- did your instructor have some examples to show you of prior Student's Care Plans? This is the best way to get an idea of how to do them. Some of my instructors asked for copies of mine so they could show her next semester students (sounds braggy, but they were the ones that I completed when I had more experience under my belt doing them. Nobody would have wanted my very first attempts!). Good luck!
  5. by   cardiacRN2006
  6. by   Daytonite
    hi, missiongirl!

    i am a older nurse who hangs out on the nursing student forums helping the students where i can. nursing care plans are something i like doing. i have a pretty good understanding of how the nanda diagnoses work. i usually look for posts from students looking for care plan help when i first come online. do you have specific questions about one specific care plan you are working on, or just care plans in general that i can help you with? do you have a care plan book? if so, which one(s)? what have your instructors told you about care plans that are making you hate them so? you must conquer this fear and face it or it will haunt you throughout school and well into your years of practice. you'll have plenty of other things to worry about without something like this hanging over your head to worry about.

    you need to realize that for school, care plans are a tool that instructors use to help you learn a number of different things. the nursing process, nursing interventions, critical thinking, pathophysiology and treatment modalities of illnesses. in the real world, some of the things you do for school care plans will never be done--like referencing the sources of your nursing interventions, and probably not having to write out those long nursing diagnostic statements with the "as evidenced by" things attached to them. there is much you can learn from one care plan alone.

    in response to your question: any good sites? the only care plan sites on the web that i have ever been able to find are either a scattered few that have those already written and put on the web for people to view as samples (such as rn central which cardiacrn2006 gave you the link to) and one or two sites where instructors have posted very general instructions on writing a care plan. your own nursing program should have given you some kind of written guideline or a lecture(s) on how they want you students to present care plans to them, so if you don't have those notes, check around with your fellow classmates because they must exist in someone's notebook. most nursing programs are very specific about this care plan writing thing. these care plans are often just as serious an endeavor as a term paper, so if you are not clear about the format that they should be written in you should talk to one of your instructors to get this cleared up.

    when you are having problems with a specific care plan, please start a thread and post your questions. i will always be watching for them and ready to help you out.

    in the meantime, welcome to allnurses!
  7. by   RNn2008
    Can someone help me please... I'm so confuse with these care plans. I'm starting my first clinical orientation on Sept.5 and by Sept. 6 we are suppose to bring in a care plan. The thing is that, I'm so clueless on how to do a care plan and my instructor(s) really haven't gone over it much with us. The only thing they gave us is a sample care plan written by some former student. I'm having a nervous break-down right about now. I don't want to show up to clinical just to be sent home for incomplete care plan.
    My question is how do we find out what to put into the care plan... ie. nursing dx, outcome criteria, nursing interventions, rationales, and evaluation? Is that suppose to just "poof" out of your own head? Are we suppose to just know those off the back of our heads or something? How are we suppose to know what to put into a care plan? HELP! HELP! HELP!
  8. by   MMARN
    Quote from RNn2008
    My question is how do we find out what to put into the care plan... ie. nursing dx, outcome criteria, nursing interventions, rationales, and evaluation? Is that suppose to just "poof" out of your own head? Are we suppose to just know those off the back of our heads or something? How are we suppose to know what to put into a care plan? HELP! HELP! HELP!
    First of all, congratulations on getting into nursing school!!! As for the careplans...in my school, we usually get to pick our patients from our clinicals. From there, we start our careplan. As for the nsg. dx, I use Doenges. This book is small and compresses most of the most common nsg. dx around. Also, you have to apply it to your pt. If the medical dx is pneumonia, your nsg. dx is ineffective airway clearance r/t mucous secretions/accumulations. Your "related to" statement has to do with what causes your particular dx. Nursing interventions have to do with implementation; what you as a nurse would do. Always prioritize whatever is most critical with your pt. Always start with your ABCs: Airway, Breathing, Circulation. This will guide you into what your interventions will be. If your ABCs are wnl (within normal limits) then you move on to safety, comfort, etc. This should all be explained in your lecture book. Your rationales have to do with the "why's" of your interventions. Why would you lift the bed of a pt with pneumonia into semi-fowler's position? Well, you must mobilize those secretions in order to help the airway. These come with common sense, but I have found a book that has helped me tremendously with my rationales: Doenges Care Plan book. It's wonderful. Your evaluations has to do with, basically assessment of your interventions. Are they working? Do you need to modify your careplan due to a change in your pt's condition?

    There are hundreds of resources anywhere and everywhere to help out. This is one web site where you've hit the jackpot. Peruse it, dig through it. You will find what you need. I hope my explanations helped. I'm sure you'll get even better advice and instructions from more experienced nurses. Good luck!
    Last edit by MMARN on Sep 1, '06
  9. by   Daytonite
    Quote from rnn2008
    can someone help me please... i'm so confuse with these care plans. i'm starting my first clinical orientation on sept.5 and by sept. 6 we are suppose to bring in a care plan. the thing is that, i'm so clueless on how to do a care plan and my instructor(s) really haven't gone over it much with us. the only thing they gave us is a sample care plan written by some former student. i'm having a nervous break-down right about now. i don't want to show up to clinical just to be sent home for incomplete care plan.
    my question is how do we find out what to put into the care plan... ie. nursing dx, outcome criteria, nursing interventions, rationales, and evaluation? is that suppose to just "poof" out of your own head? are we suppose to just know those off the back of our heads or something? how are we suppose to know what to put into a care plan? help! help! help!
    wow! i am really sorry you haven't gotten any help with this. i am assuming that you will know who your patient is going to be the day before you show up for clinical, otherwise how could you come in with a care plan for a patient that doesn't even exist? so, based on that premise this is what you will do. . .

    remember, the nursing process (1) collect data (2) plan (3) intervene (4) evaluate. this is an ongoing process. you work with what you have available. so, the day or night before your clinical the only data you will have is most likely what you are going to be able to get from the patient's chart. so, you take some blank paper with you and get information from that chart. look at the physician's history and physical and any consultations. read through and copy all the doctor's orders in chronological order. read through all the doctor's progress notes (hopefully, you can read their writing!) and look for little gems the doctor has dropped that are clues to the doctor's plan of care. read over any operative or special procedure reports to see what was done, taken out, etc. then, look through the x-ray and labwork and copy down those results. if you noticed the doctor ordering daily ptts, specifically look for those results in the lab section because there is a reason he is doing that. at home you can figure it out. lastly, look through the nursing records, specifically the medication sheets (particularly look at what they have been giving the patient on a prn basis) and the nurses notes to see what kinds of problems they have been encountering with the patient. look for fevers, high b/ps and other problems the nurses might have been having with the management of the patient.

    now, at home. . . you are going to take all this information and assemble it into a care plan for this patient. let me say that your final care plan is most likely going to change. the reason is because one very big component is missing yet. that is your assessment. but, you won't get to that until you see the patient at clinical on sept 5th and 6th. right now, just work with what you got from the chart. what you are primarily interested in is the problems the patient is having. you will be clued in to some of these problems from the nursing notes, the medication record, the doctor's history and physical, x-ray reports, labwork, and the doctor's orders. with medical diagnoses you need to know what the common symptoms of those diagnoses are and look for them in the patient. some of those symptoms you found in the chart for that patient (refer to the doctor's history and physical) are going to become the problems you are going to address in this preliminary nursing care plan.

    list the problems. group them into nursing diagnosis groups. a good recenly written care plan book can help you with this. if you have trouble though, either pm me or post a new thread for help on this forum. i realize your time span is very short (less than 24 hours), but you cannot put a nursing diagnosis on a patient without knowing what problems they are actually having. write your nursing interventions for each of the problems within the nursing diagnosis. your outcomes can be very vague, but reflect the opposite (or resolution) of the nursing diagnosis. boom! you have your preliminary care plan and you are not going to be sent home.

    after your clinical days you will add your own assessment data that you will have done on the patient to add to all of this.

    http://home.hiwaay.net/~theholt1/nurs1100/careplan.htm - this is a care plan guideline from the nursing department of fairleigh dickinson university with instructions on composing your diagnosis, goals, interventions and evaluations. includes links on suggestions for conducting interviews with patients and gordon's 11 functional patterns.

    http://www.csufresno.edu/nursingstud...gcareplans.htm - this page of links will allow you to view three sample care plans (activity intolerance, functional incontinence, and knowledge deficit) along with a printable template for the care plan. the lower part of this page has nursing care plan guidelines, information for putting together a care plan. from california state university at fresno.

    good luck! free free to pm me or post a reply regarding this process. i will help you along, but i won't do all your work for you!

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