Nursing Diagnosis Rationales

[RN in 10!]

I am curious about interventions and rationales for when writing care plans. Most resources I use have a rationale for each intervention and we are usually required to reference where we got the intervention/rationale from. As I've gotten further along in my ADN program, I am able to come up with some interventions on my own which of course I only have my rationale for when using the intervention. My question is this - do all interventions/rationales need to come from a published source when writing a care plan? This is probably a silly question, but I've always been a little confused when it comes to care plans anyway!

Thank you for any help you can offer! Have a blessed Easter weekend!

[Daytonite, BSN, RN]

i know what you are speaking about. my bsn program required it. i think it was done in order to make sure we were learning how to find and use references. in order to find the rationales for some nursing interventions you have to back pedal, or think about what sign and symptom that nursing intervention is being performed for, look it up in the index of a nursing textbook and hope that when you go to those pages of the book those interventions will be there (ha! ha!). when students ask about a specific procedure, this is generally how i have to search to find it in my books here a home.

care plans are a compilation of the patient's nursing problems listed in order of priority (1, 2, 3, 4. . .). the nursing process should have been used to determine them. the foundation of all these nursing problems is the abnormal data that was collected during the assessment process [step #1 of the nursing process]. that abnormal data is what really is the driving force behind the entire care plan. it determines what nursing diagnoses that will be used (the abnormal data serves as the evidence proving the existence of each nursing problem). it sets up the goals (we mark changes and improvement as the abnormal data changes or improves). they are the focus of nursing interventions (abnormal data is the target of nursing treatment). they are also the focus of evaluation (assessment makes a complete circle when another look at the evidence of the patient's nursing problem is made). abnormal data can be renamed as signs and symptoms. it is really these signs and symptoms that you are finding interventions and rationales for. that is why as time has gone on you have been able to come up with some interventions on your own and the signs and symptoms have been repetitive (you have run across them before). you will find that this will happen more and more as you move through your program. with some tweaking for certain conditions, yes, you will find that there is some similarity with many of the rationales for your nursing interventions.

[RN in 10!]

Thank you Daytonite for the reply! I may be in the minority but I enjoy writing care plans, I just need to improve in gathering the abnormal data during my assessments. I have not posted to this forum before (I don't know why - I'll be graduating in December so I've had plenty of time!) but I have referred back to your posts over the past year when stuck on a care plan problem. So, thank you again!