I am trying to write my first care plan, and am having a bit of trouble. I am just a student, so please bear with me! I've started it but have no idea if I am putting the correction information in the right spots or if I am correctly wording it. I have a template, and a power point explaining the steps that was given to me in class but I struggle with learning & understanding just by reading how-to instructions. Plus, there are no pictures or examples. I'm the type of learner that needs someone to walk me through it, but because that cannot happen through a screen, my main question(s) is this... So, I must go through and assess each of Gordon's 11 Functional Health Problems, which I did of course. For EACH of those, I must include a nursing diagnosis (what is/are NANDA btw...? Many I have seen speak about a NANDA list but I do not have one, I believe) with supporting subjective & objective data. (what if the patient didn't give much subjective data, or any for one of these?) I then need to create a short term goal that would occur during the clinical shift and next, include 3 interventions for this goal with a rationale for each and making sure to identify the source for each rationale! Next is where I am getting confused... we are to evaluate the effectiveness of our short-term goal. If I had my assigned patient for one day, and am not going to have that patient again next clinical shift, how do I know if my goal was met? Our care plan doesn't actually go into use & effect I know... so do we just make up whether or not our goal was met? (sorry if that is a dumb question, plz no rude comments) Anyways, how do I come up with these diagnosis's and how do I word them? Online I read that the nursing diagnosis will be written, and include "r/t or relative to" as well as "AEB or as evidenced by" but is it true that you do not include AEB for a "risk for" diagnosis? Such as risk for falls? I have to turn in my assessment data, and on the top it reads "medical diagnosis" but I have no idea what it would be for this patient if it's asking for only one. I will refrain from posting info regarding my patient for now, as I am certainly not asking for my care plan to be written for me. I am just asking for some tips on how to write/word what I say and looking for answers to the few questions I have. Please, even if you only have one thing to say, any comment is welcomed & appreciated! Thanks ahead of time!
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I am trying to write my first care plan, and am having a bit of trouble. I am just a student, so please bear with me! I've started it but have no idea if I am putting the correction information in the right spots or if I am correctly wording it. I have a template, and a power point explaining the steps that was given to me in class but I struggle with learning & understanding just by reading how-to instructions. Plus, there are no pictures or examples. I'm the type of learner that needs someone to walk me through it, but because that cannot happen through a screen, my main question(s) is this... So, I must go through and assess each of Gordon's 11 Functional Health Problems, which I did of course. For EACH of those, I must include a nursing diagnosis (what is/are NANDA btw...? Many I have seen speak about a NANDA list but I do not have one, I believe) with supporting subjective & objective data. (what if the patient didn't give much subjective data, or any for one of these?) I then need to create a short term goal that would occur during the clinical shift and next, include 3 interventions for this goal with a rationale for each and making sure to identify the source for each rationale! Next is where I am getting confused... we are to evaluate the effectiveness of our short-term goal. If I had my assigned patient for one day, and am not going to have that patient again next clinical shift, how do I know if my goal was met? Our care plan doesn't actually go into use & effect I know... so do we just make up whether or not our goal was met? (sorry if that is a dumb question, plz no rude comments) Anyways, how do I come up with these diagnosis's and how do I word them? Online I read that the nursing diagnosis will be written, and include "r/t or relative to" as well as "AEB or as evidenced by" but is it true that you do not include AEB for a "risk for" diagnosis? Such as risk for falls? I have to turn in my assessment data, and on the top it reads "medical diagnosis" but I have no idea what it would be for this patient if it's asking for only one. I will refrain from posting info regarding my patient for now, as I am certainly not asking for my care plan to be written for me. I am just asking for some tips on how to write/word what I say and looking for answers to the few questions I have. Please, even if you only have one thing to say, any comment is welcomed & appreciated! Thanks ahead of time!