Nursing care plan

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helloo,this s my 1st tym to ask here...im having a hard time making NCP..my pt. has pneumonia and pleural effusion as well.. i only need 1 NCP ..(the most prioritized,it must also hav short term goals)...

...by the way, can i include procedures like thoracentesis n my NCP?? thank u so much..

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Specializes in NICU, Nursery.

Hon,

Go read your Medical-Surgical Nursing books. The answers are all there. Focus on Respiratory problems. Spoonfeeding is not encouraged in Nursing.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

a care plan is about determining the nursing problems that a patient has and then developing strategies to do something about them. the problem here is that pneumonia and pleural effusion are medical problems which a doctor has diagnosed and will be treating. a thoracentesis is a medical treatment that a physician does to relieve accumulations of air or fluid from someone's pleural space (the pleural effusion). what we nurses treat are patient's responses to medical disease/conditions. we also assist physicians in carrying out some of their treatments. there are also things we can do independently of what the doctors do.

care planning is accomplished by using the nursing process which is our tool for problem solving. begin with step #1 which is assessment and work through each step in sequence. assessment consists of:

collect as much of this data as you can, even if this is a case study or the patient is not a real patient. nursing problems are based upon abnormal data. the next step in the nursing process is to make a list of all the data you have collected that is abnormal. this data are cues or signs and symptoms of actual nursing diagnoses (nursing problems) that the patient has. the trick is determining which nursing diagnoses they are. for nursing diagnosing, the symptoms can also be the same ones the doctors focus on as well as include the patient's response to their diseases and conditions along with their ability to perform their adls. every nursing diagnosis has a list of signs and symptoms (nanda calls them defining characteristics). before you assign any nursing diagnosis to a patient you should check to make sure that they have one of more of the symptoms listed under a nursing diagnosis. you should also double check the definition of the nursing diagnosis to make sure it is indeed the correct problem that the patient has. these two websites have that information for about 80 of the most commonly used nursing diagnoses:

once you have diagnosed your patient, the goals of nursing treatment are the predicted results of the nursing interventions you will be ordering for the specific nursing problem. nursing interventions specifically target the signs and symptoms that are the reason the nursing problem exists. everything is based upon what you found during the assessment of the patient--the first thing that was done as part of the care plan process.

you can see more examples of how care plan construction and nursing diagnosis determination are done on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. please assemble assessment data for this patient. in order to help you further, i have to see that specific information.

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I would recommend getting a nursing care plan workbook. I had trouble at the beginning of nursing school and after Ipurchased a NCP workbook, my NCP's really improved. It has tons of examples including interventions and PC's. I bought this one: Nursing Care Plans: Nursing Diagnosis and Intervention, 5th Edition

Authors: Meg Gulanick & Judith L. Myers

But there are several options out there, just find one that works best for you!

Michelle Willerford

Elsevier Student Ambassador

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Specializes in Family practice/ambulatory care.

try impaired gas exchange.

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Specializes in Family practice/ambulatory care.
a care plan is about determining the nursing problems that a patient has and then developing strategies to do something about them. the problem here is that pneumonia and pleural effusion are medical problems which a doctor has diagnosed and will be treating. a thoracentesis is a medical treatment that a physician does to relieve accumulations of air or fluid from someone's pleural space (the pleural effusion). what we nurses treat are patient's responses to medical disease/conditions. we also assist physicians in carrying out some of their treatments. there are also things we can do independently of what the doctors do.

care planning is accomplished by using the nursing process which is our tool for problem solving. begin with step #1 which is assessment and work through each step in sequence. assessment consists of:

collect as much of this data as you can, even if this is a case study or the patient is not a real patient. nursing problems are based upon abnormal data. the next step in the nursing process is to make a list of all the data you have collected that is abnormal. this data are cues or signs and symptoms of actual nursing diagnoses (nursing problems) that the patient has. the trick is determining which nursing diagnoses they are. for nursing diagnosing, the symptoms can also be the same ones the doctors focus on as well as include the patient's response to their diseases and conditions along with their ability to perform their adls. every nursing diagnosis has a list of signs and symptoms (nanda calls them defining characteristics). before you assign any nursing diagnosis to a patient you should check to make sure that they have one of more of the symptoms listed under a nursing diagnosis. you should also double check the definition of the nursing diagnosis to make sure it is indeed the correct problem that the patient has. these two websites have that information for about 80 of the most commonly used nursing diagnoses:

once you have diagnosed your patient, the goals of nursing treatment are the predicted results of the nursing interventions you will be ordering for the specific nursing problem. nursing interventions specifically target the signs and symptoms that are the reason the nursing problem exists. everything is based upon what you found during the assessment of the patient--the first thing that was done as part of the care plan process.

you can see more examples of how care plan construction and nursing diagnosis determination are done on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. please assemble assessment data for this patient. in order to help you further, i have to see that specific information.

thanks for taking the time to explain that! the websites were helpful!

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Specializes in Gerontological, cardiac, med-surg, peds.

Moderator's friendly reminder: Please keep to the topic at hand and avoid personal attacks. All such posts will be removed. Thank you and carry on :)

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