nursing diagnoses and care plan

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Hello everyone,

I am a first year nursing student. I have assignment about Chronic Obstructive Pulmonary Disorder (COPD). I have to make the nursing care plan as nursing diagnosis,planing, intervention and evaluation related to this disease. I also have to add any client and family teaching related to the care plan. I never done this kind of assignment before I am so confused and overwhelm

need help from you guys, I would appreciate it

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

a care plan is the determination of a patient's nursing problems and strategies to solve/treat them. the nursing process is the tool that works best to accomplish this task. it consists of 5 steps which adapt well to the things that you must accomplish for this assignment. this is how the steps of the nursing process are carried out, and in this order, to write a care plan:

  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. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

    [*]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)

the first thing you need to do to start this assignment is to start looking up information about copd. copd is a broad term for a group of obstructive lung diseases that include emphysema, obstructive bronchitis and obstructive asthma. look up the signs, symptoms and complications of these diseases on the websites listed on the medical disease information/treatment/procedures/test reference websites thread so you can determine the nursing diagnoses that will apply. the sticky thread https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans also has information on how to write a care plan. if you get stuck along the way with this project you can always ask a question here on the forums or search for a previous thread on a copd care plan question since this is a popular subject.

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you should purchase a care plan book,we were told we didn't need one since all of our school books had them spread out all over but It was much easier to just look thru one book,then once you have the NANDA list this makes it much easier to do the plans...

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Specializes in Emergency Department.

I'm curious about what kind of different care plan assignments students get. When I was in school, I had to select a patient from my clinical assignments and draw up a care plan for them. Do other students have similar experiences or do they receive more directed assignments?

Trying to assemble an episode on putting together care plans for an upcoming segment on the Nursing Show.

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

It will be interesting to see the kinds of responses you get back. Traditionally, students work up care plans from patients they cared for in clinicals. However, because the kinds of inpatient medical situations that they are likely to see are limited and the care plan for a student is a learning tool, many schools also utilize structured case scenarios. There are some online that can be accessed and a few include video. There are several ways a care plan can be written up:

  • case study - an essay form that present the care plan in the structure of the steps of the nursing process
  • traditional table style care plan - lists the patient problems, goals and nursing interventions in a linear style
  • care maps (concept maps) - visual diagrams that show the relationships between the elements making up the patient's problems and the nursing interventions treating them
  • critical pathways - predetermined checklists of tasks that the patient and nurse must accomplish with regard to a patient's problem - these are generally used on surgical units for post-operative cases and not written by students

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I'm curious about what kind of different care plan assignments students get. When I was in school, I had to select a patient from my clinical assignments and draw up a care plan for them. Do other students have similar experiences or do they receive more directed assignments?

Trying to assemble an episode on putting together care plans for an upcoming segment on the Nursing Show.

We had to do plans on pts that we cared for in clinical settings as well as directed care plans for practice as assigned by our instructors. While its definitely more work, I found that the practice was worth it. By the time I got to clinical, I could rattle off a half a dozen nsg dx and some interventions.

Teaching was a bit harder...because you're so nervous. But I just started with some very simple points about ambulation, deep breathing and it got easier.

We did meds with our plans and had to do teaching plans with the meds.

I posted my recommendations for a care plan book on another thread, but I liked Sparks and Taylor over Cox's. But Cox's had good rationales for the interventions.

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Specializes in Emergency Department.

Sounds very similar to my own experiences but I've had quite a few listeners to my show request me to cover this topic so I wanted to see how similar my experiences are to others.

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I found a reasonable example of a COPD care plan here if your interested:

http://www.pterrywave.com/Nursing/Care%20Plans/3.aspx

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