Nursing Care Plan

i can help you, but you have not provided any information. written care plans are the documentation of how you are solving your patient's nursing problems. to do that you must identify those problems. there is a way to do that. it is called the nursing process. it consists of 5 steps:

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.
  
• 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
    

[*]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
    

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
  • 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)

every patient is unique and has specific signs and symptoms and that is where you must start--the assessment which is where you find these signs and symptoms. it is similar to a detective who must find clues before he can arrest the person who did the crime.

start by making a list of the patient's symptoms antepartum and postpartum. that will help you determine what the diagnoses should be. if you need help determining the diagnoses, post the list of symptoms and i will show you how that is done.

for more help with care plan writing, see the information on this sticky thread in the student forums:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans