Help with Psychosociocultural Care Plan

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Anybody have a psychosociocultural care plan they can share with me? I am having trouble writing the steps and rationals I have a patient with Dementia and Depression with Diagnosis Hopelessness realted to loss of independence patient had 10 of the major characteristics

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

you are probably never going to find a care plan posted on the internet from a real patient. confidentiality and plagiarism issues. you need to use the nursing process to help determine what this patient's signs and symptoms are to get to the diagnoses. i show students how to do this all the time on the student forums. just search for my posts using the key word "diagnosis". break down dementia and depression into their symptoms and see what symptoms your patient exhibited. that will lead you to the correct diagnoses. every nursing diagnosis has its own set of signs and symptoms called defining characteristics. you can see them for each nursing diagnosis in a nursing diagnosis reference.

here are the steps of the nursing process you should be following when developing a care plan:

  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: https://allnurses.com/forums/2509305-post158.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)

this website has some information on diagnoses used for psychosocial care plans:

i can tell from the medical diagnosis of dementia that you should also end up with some physiological and safety diagnoses as well. dementia is usually the result of anatomical changes in the brain.

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