Need Careplanning guidance

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Specializes in Psych, LTC, Acute Care.

Hello all, I am at the Careplanning stage of my CPNE studies. I remember there was a thread about careplanning but I can't find it. I have Chucks scenarios and I have done the first two. I could use any advise on how to master this. TIA

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
https://allnurses.com/forums/f125/nsg-diagnosis-cpne-study-guide-307438.html
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Specializes in med/surg, telemetry, IV therapy, mgmt.

i answer a lot of care planning questions on the student forums and seldom venture into the distance learning forum. the idea of care planning, however, doesn't change if you are a distance learning student or attending a traditional program.

care planning is about determining the patient's nursing problems and developing strategies to do something about them. thus, it is problem solving. we have a tool to help us problem solve. it is called the nursing process. it traditionally consists of 5 steps. those steps easily adapt to writing care plans. printed below is how i currently present the steps of the nursing process and how to use them to develop a plan of care for a patient. i generally, don't need to go beyond step #2 (determination of the nursing diagnosis) because that is where most students get stuck. assessment is probably the most important aspect and becomes the foundation of everything that goes into the care planning process. you can see all kinds of examples of how i apply the nursing process to care planning and diagnosis determination by looking at threads i have responded to or reading the posts on this sticky in the general nursing student discussion forum:

here is the nursing process adapted 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.

[*]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.

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

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. (how to construct a goal statement: https://allnurses.com/forums/2509305-post158.html) they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]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)

nurses who are experienced already can back into problem determination in care planning quite easily. if you know why a patient is receiving some particular medical intervention, it sets off a flag in your brain that the doctor is treating some symptom or problem that perhaps you should be recognizing also. unfortunately, this kind of cueing doesn't always set off bells and whistles with inexperienced newbies in the traditional nursing programs. still, knowledge of why these things are being done is essential to understanding the disease as well as the treatment. we nurses follow the same process to diagnose and treat that doctors do. the difference is that we use a different classification system (the nanda taxonomy) for naming our diagnoses--something that is hard for many people to accept.

a good many nurses get stuck on medical diagnosing and can't seem to make the switch to nursing diagnosing. but, like doctors, we also are often treating the symptoms that are at the heart of every diagnosis we make with nursing interventions that are within the scope of our practice.

the nursing process is not only helpful in care planning. it is useful for all problem solving puzzles that come up, even the ones in our daily lives. good luck with your care plan endeavors. it may be slow going at first, but like any skill its mastery is dependent on practicing it.

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