HELP!! i need to do a careplan

Daytonite, BSN, RN · Feb 21, 2009

i take it that this is not a real patient.

a care plan is actually identification of the person's nursing problems and then developing strategies to do something about those problems. the nursing process, which is a problem solving tool, is used to help us do that. if the nursing process is followed in the sequence that it's 5 steps occur, everything falls into place much more logically (as in "critical thinking"). there are no really good examples of a care plan to show you. although there are some care plans on the internet they are not of the caliber you will be expected to produce for your instructors. i posted links to them on post #34 or 35 of the desperately need help with careplans sticky in this forum (https://allnurses.com/nursing-student-assistance/desperately-need-help-170689.html) but haven't looked at those links in a while so some of them may no longer be active. here are some of them:

http://www.rncentral.com/nursing-library/careplans
http://www.cnsonline.org/www/archive/ms/ms-07.txt - sample care plan for an ms patient
an old care plan from a ltc that i developed (poc means "plan of care"): acute poc for diarrhea.doc

most of the care plan questions now go to this newer sticky in the general nursing student discussion forum where i have explained this and where you can see answers to questions on care planning: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

step 1 assessment - everything begins with assessment. all data that goes into a care plan comes from assessing and data collection. assessment consists of:

reviewing the pathophysiology, signs and symptoms and complications of their medical condition - learn all you can about the disease. so, whether you decide to do rsv or dehydration, the first thing you will do is look up everything you can find about that disease or condition (its causes, pathophysiology, signs/symptoms, tests to detect and diagnose it, medical treatment and complications).
a health history (review of systems) - this information will come from what you will learn about the disease will you end up researching. what situations (causes) lead up to the person getting this illness?
performing a physical exam for this assignment, what physical signs and symptoms will be seen by the doctors and nurses who see this patient?
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - what assistance with adls will the disease create that require nursing help?
reviewing the signs, symptoms and side effects of the medications they are taking - what medications and treatments will the physician order? what is the nurse's responsibility in carrying out any of those?

step #2 determination of the patient's problem(s)/nursing diagnosis - the meat of any nursing plan is listing out the nursing problems that the patient has. in the "old" days before nursing diagnoses that's what we did. nursing diagnoses allow us to group more signs and symptoms together and slap a label on them. to diagnose you must have symptoms which is why you had to do that first step of assessment above. a detective must have evidence before they can arrest someone for a crime. a mechanic must figure out what is not working right with your car before he digs in and starts pulling parts out to fix things under the hood. it is the same with nursing and why you must assess first before you begin giving nursing care. assessment tells you what is wrong so you know what needs to focus your attention on. diagnosing merely gives a name to the problem. every medical diagnosis can be broken down into signs and symptoms. we use those same signs and symptoms in nursing care plans but we call them defining characteristics. every nursing diagnosis has a list of defining characteristics that are really nothing more than the evidence that needs to be present to prove that the nursing problem exists in the patient. and, unlike medical diagnoses, the patient doesn't need to have all of the defining characteristics that are listed for a nursing diagnosis. one or two will do as long as they meet the definition of the diagnosis. if you have a copy of taber's cyclopedic medical dictionary you can see what these defining characteristics are for the various nursing diagnosis because they are listed in the appendix.

you will list all of the patient's symptoms that you collected during assessment including adl needs and any possible complications. this list now becomes your defining characteristics that you will begin looking for matching nursing diagnoses.

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions are aimed at all those defining characteristics (the abnormal data collected up in step #1). you can see an example of a goal and interventions for the nursing diagnosis ineffective airway clearance here: https://allnurses.com/nursing-student-assistance/help-choosing-nursing-369473.html (see post #13) and for impaired urinary elimination here: https://allnurses.com/nursing-student-assistance/im-all-out-293100.html (see post #12).

i will help you with this, but i will not do the entire care plan for you. you can find all kinds of information about either rsv or dehydration from the weblinks listed on this sticky thread:

https://allnurses.com/nursing-student-assistance/medical-disease-information-258109.html - medical disease information/treatment/procedures/test reference websites. i recommend looking on medline plus, family practice notebook, web md, medicinenet and the merck manual.