In desperate need of some help!!

when you are doing a care plan on a "fake patient" you need to substitute textbook information about the medical disease for your assessment information. you extrapolate and make up subjective data that fits in with the assessment data. you still need to follow the steps of the nursing process, however, and in the sequence they occur in writing your 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)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

anticipated problems (the "risk for" nursing diagnoses") cannot have any aeb items. the aeb items are actually symptoms that the patient has that support using a nursing diagnosis. since "risk for" diagnoses are problems that do not yet exist, there cannot be any symptoms! however, when you are putting the nursing interventions and goals together for these nursing problems you do need to have some kind of potential problem in the back of your mind since the nursing interventions that you will develope need to focus on some potential problem you think is going to occur. i advise students to have a defined problem in mind when writing a "risk for" diagnosis although it isn't stated in the diagnostic statement.

the 3-part nursing diagnosis statement has this structural format:

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