Nursing Care Plans..

  1. Hi...I am relatively new to LTC and have done acute care for ~15 years. I am just loving the change! I have been assigned as case manager to one client and need help making a nursing care plan as this is an expectation for all case managers to complete. I am sure I haven't done one since nursing school! I don't even know where to start. My clients issues include occasional pain(relieved with T3s) , constipation (has colostomy...and T3s cause constipation) and insomnia.
    Can anyone help or point me in the right direction?
  2. Visit NS_RN profile page

    About NS_RN

    Joined: Jan '03; Posts: 168; Likes: 28
    RN
    Specialty: 16 year(s) of experience in Gen Med,LTC

    7 Comments

  3. by   adria37
  4. by   adria37
  5. by   Daytonite
    hi, ns_rn!

    i would really recommend getting yourself a care plan book to help you out. there are two types on the market in the u.s. and canada. those organized by nursing diagnosis (nanda) and those organized by medical diagnosis. i believe there are one or two authors who have specifically put together care plan books that address ltc patients. the best place to locate them would be to do a search on a website like barnes and noble or amazon. i respond to a lot of care plan questions on the forum, particularly for nursing students and i have 5 references in front of me that i use. for years, as a clinical practicing nurse (including working in a couple of ltcs myself) i used an older copy of nursing care plans & documentation: nursing diagnoses and collaborative problems by lynda juall carpenito. it is organized by medical diagnosis. there is a more current version in publication. it is a good guide to get you to the nursing diagnoses that pertain to the commonly experienced problems patients with problems like pain, a colostomy and constipation have. however, recently, since i have had to work with nursing diagnosis more and more i'm finding nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig to be immensely helpful. it has an index in the beginning that has an alphabetic listing of medical diagnoses, diagnostic procedures, symptoms and patient problems that gives you suggestions for nursing diagnoses that might apply to those things. that is a huge help when you are working from scratch! the book also has long lists of nursing interventions with specific ones for geriatrics under each of the 172 nursing diagnoses. there is a companion website that accompanies the book, a care plan constructor. the portal of entry is actually here: http://www1.us.elsevierhealth.com/ev...e/constructor/ and you can compose and it will format and print off a care plan that you direct. however, i have to warn you that the website does not contain nearly as much information as is in their book. nor does it contain all 172 nursing diagnoses in the constructor software. i have found certain nursing diagnoses to be conspicuously absent when i have searched for them. anyway, as a case manager, you need to have more detail in a care plan than what this online care plan constructor can give you. at least the ltc care plans in the u.s. that i have seen are extremely detailed and lengthy due to legal and accreditation mandates. there is another online care plan constructor at this website http://www1.us.elsevierhealth.com/me...ctor/index.cfm it does not have that index of medical diagnoses, diagnostic procedures, symptoms and patient problems as it is written by a different author.

    the care plan writing process has evolved from the nursing process and includes these steps:

    • assessment - the collection of your patient's data
    • nursing diagnosis - formulation of nursing diagnoses, goals and outcomes
    • planning - the actual writing of the care plan with nursing interventions
    • implementation - putting it into action (or more likely a notebook )
    • evaluation - updating the plan periodically
    i'm listing some websites where you can view sample care plans. keep in mind that these are done by students. i've never had to include rationale for my nursing interventions in the care plans i've done at work. that's more of an academic thing to help the students with their critical thinking and learning of nursing care. hope that helps you. you can always pm me if you have questions. i check the student forums daily for care plan questions and respond to them. you can also check out these threads for information:

    http://www.rncentral.com/careplans/contents.html - from rn central's care plan corner. here are care plans for 49 basic nursing problems. also includes a template for a blank form you can print out. each care plan gives you the language needed to write the nursing diagnosis statement, suggestions for outcomes, and nursing interventions for that particular problem.

    http://www.nursing-care-plan.com/generic.pdf - this is a 4-page care plan template. a very nice feature of this template is that in the section for the physical assessment and review of systems (ros) it lists topics under each body system that you should question or put attention on.

    http://www.nursing-care-plan.com/diabetes.pdf - this is a 3-page care plan for a patient with diabetes. the nursing diagnosis chosen was imbalanced nutrition: more than body requirements r/t excessive intake of nutrition aeb weight of 260 lbs. the care plan includes the physical assessment and review of systems, a prioritized list of actual and potential problems which are stated in terms of nursing diagnoses, short and long term goals, nursing interventions, rationales and evaluation.

    http://www.childbirths.com/euniversi...are%20plan.htm - two sample care plans from e-university. one on fluid volume excess and the other on risk for potential injury (aspiration). both include objective and subjective assessment data, outcomes, nursing interventions, rationale and evaluation.

    http://www-isu.indstate.edu/mary/carep.htm - sample care plan for potential for injury (aspiration)

    http://www-isu.indstate.edu/mary/carep2.htm - sample care plan for fluid volume excess

    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://listserv.acsu.buffalo.edu/archives/carepl-l.html - this is an archive of student nursing care plans at the state university of new york, buffalo. you will need to check out the links to the various care plans to find out what each care plan is about as they are not given in the links.

    http://www.cnsonline.org/www/archive/ms/ms-07.txt - sample care plan for an ms patient

    http://nursesintraining.8m.com/cp_copd.htm - sample care plan for a patient with copd from the nurses in training web site

    the following links to case scenarios show you, in steps, how to develop a nursing care plan using nanda languages. they are learning activities for the nurses working for a facility owned by the university of michigan. in these scenarios the nurses are directed to choose nursing diagnoses, noc outcomes and nic interventions (this is all terminology that nanda uses). unfortunately, no answers are provided. however, you can see how the process is supposed to flow from one step to the next and some of the critical thinking that goes into the making of the care plan.
    http://www.med.umich.edu/nursing/snl/cs2.pdf - this is a adult surgical care planning case study activity
    http://www.med.umich.edu/nursing/snl/cs3.pdf - this is an adult icu care planning case study activity
    http://www.med.umich.edu/nursing/snl/cs4.pdf - this is a pediatric care planning case study activity
    http://www.med.umich.edu/nursing/snl/cs5.pdf - this is a pediatric icu care planning case study activity
    http://www.med.umich.edu/nursing/snl/cs6.pdf - this is a prenatal care planning case study activity
    http://www.med.umich.edu/nursing/snl/cs7.pdf - this is a psychiatric care planning case study activity
    http://www.med.umich.edu/nursing/snl/cs8.pdf - this is an ambulatory patient care planning case study activity

    have fun!!! there's not too many of us that really are in to this care plan writing.
  6. by   tyratania
    Can anyone help me make a car plan please.I stuck on my assignment.
  7. by   NS_RN
    Wow daytonite! Thanks so much...I appreciate the time you put into your reply and have bookmarked most of those sites!
    Thanks again!~
  8. by   Daytonite
    Quote from tyratania
    can anyone help me make a car plan please.i stuck on my assignment.
    i've sent you a private message. you can either answer me back that way, respond back with another post to this thread, or start another new thread with a specific question about your care plan assignment on either of these nursing student forums:
    i have a 5-hour class myself this afternoon, so i will be offline until later tonight, but i am always willing to help someone with a care plan. but, i need to know what it is you need help with.
  9. by   MDSnursing
    Daytonite,

    Thank you for sharing the wealth of information you have accumulated! Wow, as an MDS Coordinator maybe I've got a 'virtual resourse' with you my friend. Thank You so much!

    (Now to try and find the time to read and research and remember....)

    Dara

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