How in the world do you "make" a care plan?

mcpnurse · Feb 2, 2010

do you have a care plan text book? a care plan involves the nursing process... so you need a collection of data (subjective/objective), make a nursing diagnosis, predicted outcome (your goals for the patient, involving short term & long term) , then give a few nursing interventions... then rationales for each of the interventions (why r u doing such & such?) then you evaluate the outcome.

jeweleebleu · Feb 2, 2010

Subjective and Objective Data (what the patient is saying and what it is you see going on with your patient) Nursing Diagnosis (Remember it is not a medical diagnosis), Expected Outcome (what you want to see happen with your patient or what you want to prevent), make sure you put your Interventions as the nurse (ie: have patient consult with the dietitian, refer to outside support group, reviewing lab work...etc), Rationale (why you are doing it) and Evaluation/ Reassessment (was what you did in your intervention giving you the expected outcome).

or another way to go is:

A: Assess

D: Diagnosis

P: Plan

I: Implement

E: Evaluate

Hope some of this helps...Good Luck!!!

Silverdragon102, BSN · Feb 2, 2010

Moved to the general student discussion forum

We have a few threads discussing care plans, may be worth doing a search

Forever Sunshine, ASN, RN · Feb 2, 2010

Find nursing diagnoses'(sp?) that apply to this patient. Then create goals for each one. After that list about 5 nursing interventions for each diagnosis and evaluate how the patient will respond.

Diabetic patient based on nutrition-

-Risk for imbalanced nutrition: Less/More than body requirements

- Self Care Deficit: Nutrition

- Knowledge deficit for disease process

Renal Failure/Dialysis Patient

- Ineffective Tissue Perfusion: Renal

- Impaired Urinary Elimination

- Fear

I dont want to tell you anymore because its assignments like these that really open your eyes to care plans but I want to point you in the right direction.

Daytonite, BSN, RN · Feb 2, 2010

you have never had to write a care plan before? see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

a care plan is a list of a patient's nursing problems and the strategies you will take to do something about them. in this case your instructor has specifically told you to focus on one nursing problem--nutrition. so, what you need to do is read about diabetes and renal failure and find out what specific dietary problems these two kinds of patients have. for each patient, you need to list out those diet problems (they will actually be symptoms of the nursing problem). then you will name each nursing problem with a nursing diagnosis. each nursing diagnosis has a definition and signs and symptoms (those dietary problems each patient will have). based on each patient's signs and symptoms of their dietary problem you will come up with some strategies to do something for those signs and symptoms that the diabetic patient and the renal failure patient has as well as some goals.

hint: diabetics have to watch their carbohydrate intake. renal failure patients generally have to watch their fluid and electrolyte intake.

and, yes, in nursing school you often have to self-teach yourself a lot of things.

Laker2011 · Feb 2, 2010

don't forget when you do your interventions to include different types. i.e.

pt teaching

independent nursing action

dependent nursing action such as following the doctor's orders

holistic

etc

my teachers drastically marked us down if we stayed stuck on one type