Need Care Plan Help

[ybstressed, LVN]

Ok...here's the deal. I have 7 care plane due on the 23rd. My class is online and my instruction has not taught use anything about care plans. All the students are having issues with this instructor and she is not answering her emails. The care plans that are due on the 23 are not patient specific. She has listed symptoms such as pain (acute and chronic), CHF, and COPD...... So I was hoping I could get some guidance here.

1. I have been review multiple formats and I am totally confused. What does a care plane need? The instructor has not given specifics on what is needed so please help. I have examples in my books and they list assessment, nursing diagnosis, expected outcome, interventions, and evaluation of expected outcome. Does this seem good enough?

2. I purchased a book called "ALL IN ONE CARE PLANNING RESOURCE BY SWEARINGEN". Is this a good book to use.

Thanks

.

[Daytonite, BSN, RN]

chf and copd are not symptoms. pain is a symptom. we assess patients (such as patients with chf and copd) in order to determine their symptoms. from their symptoms we then develop a nursing care plan. a nursing care plan is a determination of the patient's nursing problems (nursing diagnoses) and strategies (nursing interventions) to help them. nursing care plan books contain all kinds of examples of specific nursing diagnoses for many of the most common medical diagnoses. the problem with them is that may not contain complete nursing diagnostic information, but just the major nursing diagnoses or there would be too much repitition in the book.

i am not familiar with swearington's book. i do have a copy of nursing care planning made incredibly easy which explains how to write a care plan following the steps of the nursing process. it also includes a cd that has nursing care plans for common med/surg, ob, peds and psych conditions.

there are lots of care plan questions that have been answered on this student forum and this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. you can get plenty of ideas for a medical disease or condition to write a care plan on as well as instructions on how to approach doing this. i write these instructions 2 or 3 times a day when responding to questions.

some suggestions that you could care plan for are diabetes and any of its complications, chf, copd, dvts, pvd, alzheimer's disease, pneumonia, a broken leg, post op surgery patient, osteoarthritis, chronic renal disease, cancer of a specific organ, mi, dehydration, otitis media in a child, gerd, uti, cystic fibrosis, bell's palsy.

get started on a care plan and if you have questions or difficulty, post on this forum and i will help you out.

these are the steps of the nursing process and what goes on in each in relation to care planning:

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)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

  [*]always sequence actual nursing problems before potential (risk for) or anticipated problems

  [*]use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance

  • http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs - maslow's hierarchy of needs
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]how to write goal statements: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

[ybstressed, LVN]

Thanks for the reply. Sorry...I know COPD and CHF are not symptoms....I just freaking out and typing. Thanks you so much for the help.

[crochetangel2]

This website has free careplans that are in PES format that you can find a nursing diagnosis(problem),expected outcomes and nursing implementation.http://http://www.rncentral.com/nursing-library/careplans click here

You can use outcomes from other diagnoses for a different nursing diagnosis. Type in Free Careplans in the search at the above site. Hope this can help.

[ybstressed, LVN]

Thank you crochetangel2...working a full time job and going to nursing school is the hardest thing I have ever done....thank you for the help

[ybstressed, LVN]

I just noticed I can't spell....wow I need sleep...

[crochetangel2]

Yes, Going to nursing school and being a mom is a hard work. You can do it! Don't give up it will be all behind you soon and it will be a big regret if give up so only keep going ahead. Think positive and don't procrastinate. Put a sign on the refrigerator to keep a focus on your goal. It is the hardest thing you have every done but it will be the best thing you have ever done. You win the reward in the end!! This way has helped me conquer fears and accomplish goals.

Margie

[prudence09]

Don't forget with care plans you need a goal for the patient to achieve that is measurable(time) and realistic. Also your outcomes need to be measurable and realistic. EX: Patient will be able to explain measures to prevent infection during clinical shift. Hope this helps.