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I need help with a Care plan PLEASE!!!

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by mzwest83 mzwest83 (New) New

1,511 Profile Views; 6 Posts

I have a care plan due this week. I know its short notice but the teacher told us it was due the last week of class but the syllabus states this week so I want to be safe then sorry. I have have no clue what I am doing. When I asked the instructor How to do these I was told to get a book. I am strapped for cash and on the wait list at the library thus I am turning to you for help. It has to have 3 nursing diagnoses and be from NANDA. For each diagnosis must have objective and subjective data for a assesment and mds sheets, short and long term goals and out comes and 3 interventions with rationales for each one. each must have a holistic intervetion and rational too.

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psu_213 has 6 years experience as a BSN, RN and specializes in Emergency, Telemetry, Transplant.

3,869 Posts; 28,234 Profile Views

With all due respect, we are not going to write the care plan for you...in addition, it would totally impossible to do when we know nothing about the pt.

Remember your nursing process. What did you come up with in your physcial assessment? For example, if they a cough, hypoxia, and adventitious breath sounds, look for a respiratory dx. that fits. Go from there.

There is absolutely nothing in your lectures or in any of your texts about how to complete a care plan? When I was in nursing school and had to do my first care plan it was more than 'fill in the blank'--i.e. we had to glean from the reading the correct way to do the care plan...it was not spoonfed to us. However, I find it unlikely that you have no guidance whatsoever on how to do this.

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6 Posts; 1,511 Profile Views

With all due respect I never once asked for any one to write my paper for me. Not once. I was asking for guidance. Second I am finding that my school lacks in the teacher department. We have learned nothing so far on writing a care plan or case study. My class is in a panic its not just me. Although most have bought books at different stores for their own use I can't afford it. I was given a scenario and told to do a case study no fill in the blanks or lectures. I thought as nurses I didn't have to say it but if you are going to leave rude comments or be mean don't post. I am just looking for help not to be treated like a idot.

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OCNRN63 is a RN and specializes in Oncology; medical specialty website.

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Sorry, but it looked to me that you were asking for people here to essentially write the care plans. Couldn't you have clarified with your instructor when the plans were actually due since there seems to be a discrepancy?

IIRC, there is information on the internet about writing care plans. You may need to do some looking around google, but you should be able to find what you need.

It will be impressed on your mind more if you do the hard work for it.

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psu_213 has 6 years experience as a BSN, RN and specializes in Emergency, Telemetry, Transplant.

3,869 Posts; 28,234 Profile Views

mzwest83 said:
With all due respect I never once asked for any one to write my paper for me. Not once. I was asking for guidance. Second I am finding that my school lacks in the teacher department. We have learned nothing so far on writing a care plan or case study. My class is in a panic its not just me. Although most have bought books at different stores for their own use I can't afford it. I was given a scenario and told to do a case study no fill in the blanks or lectures. I thought as nurses I didn't have to say it but if you are going to leave rude comments or be mean don't post. I am just looking for help not to be treated like a idot.

What was rude about my comment? Even re-reading your first post, it seems as if you want someone to just tell you what to write. I gave you some suggestions, but, as I said, it is pretty much impossible to know where to go with the CP without any background on the pt. I offered guidance, if you don't want it then fine..I won't post, but I can guarantee that no one on AN will write this assginemnt for you.

Maybe you school is lacking in the teacher dept., but that does not change my thoughts that there has to be some guidelines available for doing this. Perhaps team up with some other students to try and pools thoughts and resources to get an idea of how to do this? For better or worse this is something all nursing students have to go through.

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6 Posts; 1,511 Profile Views

I called my instructor today who stated that the syllabus could not be changed. That it is what it is. I am searching google but not finding what I am looking for. :cry: This is just beyond frustrating. I want to learn how to do this. I don't want to copy some one stuff and get a grade. When I say she just handed us it and said do it, she did. I have no start point no help sheet nothing.

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Subjective:

What the patient says, the family, the doctor, a nurse/

Usually in quotations

**Note if your patient is nonverbal, you can still have subjective data from other sources.

Objective: (Note your Topics to the side)

Start with a brief overview of the patient.

Example: 78 yo white male admitted 6/12/09 with COPD exacerbation

PMH: include a comprehensive past medical history of your pt

Orders: orders that are specific to your ND or that may contribute to supporting your ND statement

  • Interdisciplinary assistance such as PT, OT, RT
  • Diet
  • Activity
  • Oxygen

Radiology: report any radiological findings that may support or contribute to your ND statement

Labs: what laboratory findings are pertinent to supporting your ND statement

Medications: only medications that can support your ND statement

Assessment findings: can include an array of things, but only if relevant to support

  • Intake and Output: include if can support your ND
  • Vital Signs: usually a great inclusion to support most ND
  • Wound appearance
  • Mobility performance
  • System Assessment: that is pertinent to your ND

Example; Impaired Gas Exchange-do Resp assessment

P= Problem

E=Etiology

**May use Secondary to a diagnosis after the etiology if it permits

S=Signs and Symptoms

****Note that if it is a Risk for diagnosis you will only have a PE format without signs and symptoms

PATIENT WILL.....

This is what the nurse hopes to achieve by implementing the nursing interventions

COMPONENTS

Subject: PT will

Verb: action patient is to perform

Condition: explains how the behavior is to be performed

Criteria: Time frame

BE SPECIFIC

Patient will increase mobility by the end of 3-11 shift as evidenced by independently ambulating to chair.

NURSE WILL.....

This is what the nurse will do to assist the patient in accomplishing the goal.

COMPONENTS

Subject: Nurse will

Action verb: precision--educate, demonstrate administer

Content: the what and where of the order

Time Element: when, how long, or how often the action is to occur

Rationale: Under each statement you must support this nursing intervention with a source as to why it is important

Nurse will perform range of motion every 2 hours.

Rationale: Exercise increases joint flexibility, stability, and range of motion.

Sources: you must have at least 2 sources per care plan. We encourage use of articles and lectures as well. Format in APA.

Goal Met...

Goal partially met...

Goal not met...

This is merely reporting that the goal was accomplished or not.

Goal partially met.

Patient ambulated with assistance of 2 to the chair at 9:30 pm.

***Note that if your goal is met or not met, you need to state what you would expect to find or what you found.

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nursecat64 has 12 years experience and specializes in med/surg, home health.

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mzwest83 said:
I have a care plan due this week. I know it's short notice but the teacher told us it was due the last week of class but the syllabus states this week so I want to be safe than sorry. I have have no clue what I am doing. When I asked the instructor how to do these I was told to get a book. I am strapped for cash and on the waitlist at the library thus I am turning to you for help. It has to have 3 nursing diagnoses and be from nanda. For each diagnosis must have objective and subjective data for a assessment and mds sheets, short and long term goals and outcomes and 3 interventions with rationales for each one. Each must have a holistic intervention and rational too.

I was poor in school also. I got a lot of books second hand. There is a great book called "Care plans made easy" that helped me. Does your school have a bulletin board that you could post on asking for used nursing books? I found books (and scrubs, bp cuff, and other stuff) in 2nd hand stores.(the staff got to know me and started saving nursing stuff that I might need/want) when it came in. Yard sales..Etc. Also putting a "Wanted" ad in a newspaper might help. There are some free ones. Or even craigs list might work. I know this may not help for your current problem, but you are going to need books snd stuff in the future too. Another thought-hospitals often have reference libraries for research work available. Hope this helps. Good luck!:)

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danarooo is a BSN, RN and specializes in Home Health,ID/DD, Pediatrics.

119 Posts; 3,761 Profile Views

Do you have a half priced book store in your area? You can find good care plan books with all the NANDA nursing dx's you'll need at half priced books. I'm assuming your at the beginning of your nursing school, in which case it can feel very daunting. Good luck, you have gotten a lot of good info here already, links etc...

Try not to panick, if you don't do so well on this one believe me there will be many many more chances to get it right. Relax and rely on the basics of what you have learned so far. Look at all the vitals, labs, meds etc...and that will give you a good starting place. As for the poor instructor, I had a few of those too it's not uncommen in nursing school. If there are any other faculty members that you know you may ask them for some guidance as well. Good luck.

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OCNRN63 is a RN and specializes in Oncology; medical specialty website.

5,978 Posts; 54,356 Profile Views

mzwest83 said:
I called my instructor today who stated that the syllabus could not be changed. That it is what it is. I am searching google but not finding what I am looking for. :cry: This is just beyond frustrating. I want to learn how to do this. I don't want to copy some one stuff and get a grade. When I say she just handed us it and said do it, she did. I have no start point no help sheet nothing.

All I can tell you is I typed in "care plans NANDA" in google, and I found a site right off the bat on page one that explained the process and gave sample care plans. I can't name the site because of TOS.

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18 Posts; 4,249 Profile Views

God bless Daytonite. Sure do miss her.

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Careplans have got to be one of the most frustrating things in nursing school. Very few people get it right there first time so don't get discouraged. I was horrible with them at the beginning of nursing school but eventually I got it down. Take a look at this website, I have used it in the past.

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