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Nursing Care Plan help?!

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by LexaRN LexaRN, BSN (Member) Nurse

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It's my first time to make a nursing care plan..Can someone here help me..

His Initial diagnosis is fracture, Open II Comminated, Proximal ulna ®

Fracture, dose, complete, displaced, transverse D/3 femur ® 2 degrees to VA

No Final diagnosis yet

Initial

My cues are (subjective) "I have a 8/10 pain in my knee and elbow"

"I have difficulty in moving"

Would suggest what are the Nursing Diagnosis, Desired Goals, Nursing Intervention, Rationale for that? I have already some but I'm not sure with my answers. Please help me, I'm so newbie in nursing care plan.

Rain

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Daytonite is a BSN, RN and specializes in med/surg, telemetry, IV therapy, mgmt.

2 Followers; 4 Articles; 14,602 Posts; 101,293 Profile Views

Imformation on how to write a care plan are in these two threads on allnurses:

From the information you've provided I can develop two nursing diagnoses:

I've provided you with links to nursing diagnosis pages from the Ackley Ladwig online care plan constructor that has goals, nursing interventions and rationales. However, you should also be using your own nursing textbooks to develop your care plan interventions.

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18 Posts; 1,355 Profile Views

Thank you so much! It is really helpful. How I wish I could return a favor. Thanks again.:wink2:

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Daytonite is a BSN, RN and specializes in med/surg, telemetry, IV therapy, mgmt.

2 Followers; 4 Articles; 14,602 Posts; 101,293 Profile Views

Return the favor by learning the nursing process and the steps on how to write a care plan. Then, teach others how to do the same.

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We are starting all of that next week. I am excited, but nervous. I know we can always count on daytonite. You are great, and a big help to everyone. Thanks.

We are doing our fist care plan in class as a group project, and then wrapping the semester up the following Friday. It has gone by really fast. It has been a serious challenge so far, but it is really so interesting. The summer semesters are a killer.

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Daytonite is a BSN, RN and specializes in med/surg, telemetry, IV therapy, mgmt.

2 Followers; 4 Articles; 14,602 Posts; 101,293 Profile Views

we are starting all of that next week. i am excited, but nervous. i know we can always count on daytonite. you are great, and a big help to everyone. thanks.

we are doing our fist care plan in class as a group project, and then wrapping the semester up the following friday. it has gone by really fast. it has been a serious challenge so far, but it is really so interesting. the summer semesters are a killer.

if you have a care plan book, read the first few pages where they talk about the nursing process. a care plan is nothing more than the written reflection of the nursing process. a lot of people just don't get that connection and sometimes go entirely through their nursing programs without ever understanding just what the nursing process is. it's the first three steps that nursing school spends the most time teaching you:

  1. assessment (data collection) https://allnurses.com/forums/2228927-post5.html
  2. determine your problems (formulate nursing diagnoses)
  3. planning (write measurable outcomes and nursing interventions)

and

  1. assessment


    • leads you to the


[*]

nursing diagnosis

  • which further leads you to the


[*]

outcomes (goals) and nursing interventions you will develop

these steps are all related and dependent on each other

each step is quite involved. some students don't seem to make the connection that they are all related to each other and that they are part of this larger process. another problem that i am seeing is that some don't understand that each nursing diagnosis has signs and symptoms assigned to it. this is why, as a beginner, using a good reference book of nursing diagnoses is going to help you learn what they are. certain nursing diagnoses keep getting used again and again, particularly when you are working with medical patients, so people tend to get very good at working with those diagnoses. however, there are now 188 nursing diagnoses that nanda has on their list. when you need to get into ones you're not accustomed to using, you need to go back to references to make sure you are diagnosing correctly. there is nothing wrong with using a reference to verify you are correct. it's the smart way to work. yet, you will see fellow students conjuring up a nursing diagnosis and trying to make it fit into their patient situations. because they don't understand the underlying process to begin with, they'll sit there stumped because they inherently "get" that something just isn't right when they don't have things going on with their patients that don't seem to "fit" with the nursing diagnosis they want to use. that is not the way to do this process! others believe that a medical diagnosis automatically locks a patient into certain nursing diagnoses and that is just not always true.

one of the things i'm trying to do this summer is look up information on how doctors are being taught the process of medical diagnosis. the process of doing that should also apply to the process of determining nursing diagnosis as well. i'm curious as to how a rookie med student learns how to diagnosis a disease given a bunch of symptoms. is it just plain old memorization at first? and nursing students all need to keep in mind that it takes medical students years to become proficient at diagnosing medical conditions. this also applies to nurses becoming proficient at diagnosing nursing conditions. the basis of it all is that dog gone assessment. it's going to make or break your diagnosis.

if your school is using nanda as the basis for nursing diagnosis, one of the best (and cheapest) resources you can use is from nanda itself: nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. runs about $30. it lists all 188 nursing diagnoses, their defining characteristics and related factors. this is the bare bones information that is repeated in every care plan book that is on the market today. all the other commercial care plan books just enhance all that information by adding suggestions for goals and interventions. however, you can get your nursing interventions from your nursing textbooks. goals (or outcomes) are the result of performing your nursing interventions.

you can always pm me for help. print out a copy of the critical thinking flow sheet for nursing students at the bottom of my posts as well.

here is information about the nursing process. you might want to print these pages out to have the information to add to what your instructors are telling you. we'll get you through this!

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I do have a careplan book, and I will rmember that. That is going to be a big part of this next exam. We are reading a chapter right now that expains all about it. I think it will fall into place.

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