Is this doable?

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Okay, I am in my third week of ADN, first semester. Our first clinical was more or less cancelled, yet we are supposed to write this huge nursing process assignment based on our clinical patient only now it is to be a ficticious patient of our choice. This is a huge assignment. We have not had our nurisng process lecture yet, we have had the opportunity to see a sample of a completed assignment like for five minutes while listening to other things being said. Anway this is to include our data cluster findings, as well as charts and lab tests we have never seen.

We do have a format to go by I am going to try to attach it. Can anyone help me to try to understand how to even start? I am super stressed and lost. If I had seen an actual patient or even the patients chart I might have been able to start, but I really have no clue where to begin. Thank you for reading of my plight.

Margaret

NCP_Guidelines.pdf

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Specializes in ICU, PACU, Cath Lab.

Well since you can make this all up...first I would pick a disease process that intresets you...COPD, CHF, Diabetes, MI....then I would make up a patient demographic...female, male age, med history...so like if you decided to do an admission DX of MI...patient has a hx of diabetes, HTN, etc...ok then you need labs...so look up in your book...labs on your specific disease..they should have normals in there then you will just have to deviate from that...Do a head to toe assessment...make thingst that would be appropriate..crackles in the lungs, edema...Then hit the Nursing Diagnosis...if you have a nursing diagnosis book..it will also have nursing interventions and client outcomes...I think once you start you will see that it flows out pretty easily...you just have to get in the swing of it!!! GL and I hope this helps...let me know if you need anymore help...or if this made absolutely no sense!!!

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Thanks Calla, what you say does make sense, I am about to give it a GO. Thanks for your assistance.

Margaret

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

hi, margaretptz! yes, this is doable. i've looked over the guidelines for the nursing process assignment that you attached to your post. this is merely the nursing process, specifically directions on how to write a care plan. i think you will find some ideas and help by going through some of the posts in these two threads:

i often find that one of the moderators adds replies that i give on writing care plans to these threads. if you have a care plan or nursing diagnosis book the very first chapter or two usually details the nursing process as it pertains to writing care plans.

the first step always involves collecting data. this includes not only your physical assessment but all the data you can collect from the patient's written record. in the absence of that, you look to the signs and symptoms that normally accompany a medical diagnosis. nurses are also able to use the same signs and symptoms of a medical diagnosis (not the medical diagnosis itself) to determine their nursing diagnoses and develop their nursing problems and nursing interventions. i see that in part a your instructors have underlined "and abnormal findings in each category" in item #1 under assessment data. the reason is that it is the abnormal findings, or in nanda language "defining characteristics", that help to define each nursing diagnosis. those abnormal findings are what you are grouping together when you are doing your data cluster assessment. those groupings, or data clusters, or abnormal findings, are actually defining characteristics that match with specific nursing diagnoses. the trick is in knowing what abnormal findings cluster to which nursing diagnoses. the way you determine that is by having a book of nursing diagnoses to use as a reference that lists this information. i think your instructors could have been a lot clearer in putting this information together on this guideline, but that is just my opinion and probably why i end up answering a lot of care plan questions. i try very hard to put this stuff in simpler language that students can understand.

as calla2114 has suggested pick a medical disease that fits your fancy. you'll need to look up information about the disease itself and probably some of the pathophysiology since part b, section i of your guideline is asking for this. you also need to find out what tests the doctor normally would order to determine the presence of the disease and monitor it's progress. you'll need to know the signs and symptoms of the disease because these will become your abnormal findings which you will divide into clusters that will become the defining characteristics of your nursing diagnoses. these defining characteristics will also help you to determine your short and long term outcomes.

you can use family practice notebook to get the thumbnail pathophysiology and, most especially, the diagnostic tests and medical treatments that are normally done for the various medical diseases. i would suggest you not pick something too complex like diabetes (has too many complications) or a heart problem. this is the site. use the search box to find a disease.

http://www.fpnotebook.com/index.htm

at these websites you can link in to a whole bunch of student case studies that will give you an idea of how these are written up. it might also give you an idea for a disease to pursue:

these care planning exercises will give you an idea of how the nursing process is used to develop a care plan:

if you still need help, please ask. the first care plans generally take a lot of time to write. the important thing is that you understand what goes into the steps of the the process. happy care planning!

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Wow. thanks Daytonite, you sure have a knack for coming to the rescue, have you ever considered becoming a nursing instructor? If this doesn't get me through this assigmnent nothing will. I am feeling a lot better about it now. You and Calla are the greatest. Thanks

Margaret

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

No, I've never considered becoming a nursing instructor. However, I've been mentoring and precepting nurses for many years in the clinical area. It's kind of the same thing. I wrote care plans in nursing homes for many years and I was on a care plan committee in one hospital where we developed standardized pre-written plans of care for common patient problems that the staff could pull and then customize. Trust me, I can tell you from many years of clinical experience that a good many nurses would never write another care plan in their career after nursing school if they can weasel out of it! In some places the managers have to make care planning part of the yearly evaluations or it never gets done. Would you be surprised if I told you that Medicare law clearly states that an RN must have a plan of care in every patient's chart? The day is coming when parts of care plans are going to need to be reduced to numerical data and transmitted to Medicare for statistical data gathering which is one of the reasons that NANDA was developed.

Writing a care plan encompasses every principle of critical thinking and the nursing process. It is probably THE most complex skill that every nurse has to learn. Writing a care plan for a nursing school instructor is a much more complex activity than what is required at a job. What nursing instructors realized many years ago about them was that they encompassed all the features of critical thinking, prioritizing and organizing, not to mention that you needed to have some knowledge about the patient's disease process and treatment as well as the potential nursing interventions. This is why I say that the very first ones you write will take such great time and effort. Do them as your instructors are asking because your grade depends on it. But also realize that somewhere in all the confusion you ARE using the nursing process to put all the information together.

In my BSN program, we had to "assess" each patient for six specific stressors in their life. These were specific and based on the work of an anthropologist whose definitive work we had to read in a separate course we all took before we even got into our clinical classes. Every care plan we wrote had to have complete history and physical assessment information in them as well as show the specific information we had gathered on these six stressors or we lost MAJOR points in our grade. Every one of these care plans took the same effort as writing any major term paper. I saw from the guideline sheet that you attached that your instructors have you doing a similar thing. You just have a different set of criteria than my program had. So, don't forget to list each one of those special areas and either bold-face or underline them so the instructor can find them easily and know you included them. This all comes under the heading of "assessment" which is only Step #1 of the nursing process and care plan writing process. It's a humdinger and most students totally miss the importance of this assessment data part of their care plans. This is, by far, where you will spend at least 50% of your efforts on this paper.

Step #2 is to take ALL this information and extract out all the stuff that is abnormal. That abnormal stuff is what you use to pick nursing diagnoses. Clustering, or grouping, of the abnormal assessment information is something that we owe to NANDA and nursing diagnoses. Each and every nursing diagnosis has a list of abnormal signs and symptoms (they call them defining characteristics). This is why, as a newbie, a good nursing diagnosis book would be a great guide for you to use. Your mission, grasshopper, is to figure out which nursing diagnoses to pick out and use. Think of it as having a shopping list of abnormal assessment items and going shopping for the perfect nursing diagnoses. It's kind of a matching exercise and in many ways it can be very creative because sometimes there is more than one nursing diagnosis that you can use for a group, or cluster, of abnormal assessment information give or take a few assessment items here or there. What you will find is that there are a handful of nursing diagnoses that tend to get used a lot, so people get really good at knowing what abnormal assessment findings fit with them.

The other 50% of your time will be spent in developing your nursing interventions and outcomes. The abnormal assessment data ,still to this day, is what drives all the interventions and outcomes. That has never changed. NANDA just confused everything up when a handful of abnormal items became part of one diagnosis. Now, instead of all your nursing interventions addressing only one abnormal assessment problem (as we did it back in the 70s) you now include interventions for a handful of abnormal items that are grouped into one diagnosis. If you don't have a nursing care plan book, I can give you weblinks to two online care plan constructor sites where you can get some good ideas for nursing interventions and outcomes for the most commonly used nursing diagnoses. They are actually posted somewhere in the two sticky threads I gave you in my previous post.

Hope that helps you a little further. I've been there and had to do what you're now doing. If you are having any problems at all, please ask.

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