Need help with a care plan

you really should get a book to help you write these care plans. I have Doenges' Nurse's Pocket Guide that works really well for me. Its hard to get used to writing these care plans without one of these books. Good luck!

You don't necessarily need to have a "Related to" with a "risk for" diagnosis you have what are known as risk factors. Things like, presence of secondary diagnosis, forgets own limitations, ect.

At my school we must have a related to for all diagnoses, including risk diagnoses. We don't have to have "as evidenced by" for risk diagnoses.

ya i have to have a related to as well....

if, whenever you have to write, "related to," you think, "because he has..." then you will be miles ahead of most people. it's that "because" word that you have to focus on, because if you know that, the why, then your way is often made clear. if a "because he has..." doesn't make sense, then you're looking down the wrong path.

Remember that each nursing diagnosis is going to have interventions. The interventions are what you are going to do to help the patient. In this case, the diagnosis could be something like Risk for falls r/t stroke. You have no AEB (as evidenced by) because this is a risk diagnosis and nothing has actually happened yet. After you pick a diagnosis, start thinking about what you are going to do for the patient. The interventions in this case are going to all be preventative; the patient hasn't fallen yet, but is at risk for falling, and you want to keep him from falling. Here are some interventions you could think about:

• Orient patient to new surroundings. Keep necessary items (including water, snacks, phone, and call light) within easy reach.
  
• Maintain an uncluttered environment with unobstructed walkways. Ensure adequate lighting at night to help prevent falls in the dark. In addition, keep side rails up and bed in the lowest position with the brakes on.
  
• Assist patient as needed with ambulation. Instruct patient to ask or call for assistance with ambulation. Frequently check of patients who may forget to call for assistance.
  

The outcome is what you want to see happen as a result of the care you have given. For instance, you want to ensure that the patient is free from falls, that they are safe, and that they have as much independence as possible. An outcome in this situation may be something like this: Outcome: falls protocol instituted, patient instructed to call for help before attempting to ambulate, call light, phone, and personal belongings placed within easy reach, and bed in low position with side rails up. Patient will be free from falls during this shift.

thank you mattmrn2013!!! thats exactly the help that i was looking for! :)