let me first give you links to a couple of threads on the nursing student forums which you should be reading. there is a lot of good information among the posts.
before i go any further, you need to remember that the practical application of the steps in the nursing (written care plan) process is:
- nursing diagnosis
i know you've heard this before as you are a couple of classes into your nursing education. however, you have to follow these steps in order to formulate your nursing diagnoses correctly.
now, i don't know if this patient of yours is a real patient or a case study, but i can tell you one thing. it all starts with the assessment and collection of data about the patient. for real patients that includes culling every bit of information out of that patients written medical record. read and take down information from the doctor's history and physical, his progress notes, any diagnostic procedures that were done, lab results, respiratory therapy notes, physical therapy notes, dietary notes, social service notes, the nursing admission assessment, nursing notes and medication records. you are also doing your own physical assessment of the patient. you are looking for "symptoms" and non-normal reactions by the patient to things happening to them. nanda calls these defining characteristics
, but they are really just symptoms.
for non-real patients in case studies you look to the diseases that are listed for the patient and make a list of the symptoms for those diseases. for the foley catheter, you need to know why the patient had the foley catheter inserted in the first place. that will lead you to a problem he/she is having that you need to address. those lists of symptoms become the list of data that you work with. a symptom is an objective observation or a subjective perception of the patient. symptoms are not for the sole use of doctors in formulating their medical diagnoses. we nurses use symptoms, or defining characteristics (let's give nanda their due), to formulate our nursing diagnoses as well.
that list of all those symptoms, or defining characteristics, then becomes your shopping list for nursing diagnoses. your next step in the nursing process is to see how you can group some of the symptoms into the right mix to satisfy the requirements for a particular nursing diagnosis. now, there are some care plan and nursing diagnosis handbooks that are a little better at helping you do this than others. nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig is one of them because it includes an index of symptoms at the very beginning of the book that cross-references you to potential nursing diagnoses. i believe there are one or two other books that do something similar, but i only have personal knowledge of this book. you will give some nursing diagnoses more use than others, so you will get to know their defining characteristics very well. others you just have to look up in a reference book.
once you choose a nursing diagnosis, the patient's "symptoms" or defining characteristics that support it become the problems that you will write your nursing interventions on for that nursing diagnosis. in other words, all those symptoms that you came up with on your list are things you are going to find nursing interventions for. are you seeing the cycle as to how this works?
actual diagnoses are always sequenced before anticipatory, or potential, diagnoses. anticipatory diagnoses are the ones that begin with the words "risk of". they are patient problems that don't really exist, but could. your nursing program should have also directed you to sequence care according to an already existing standard such as maslow's hierarchy of needs or gordon's 11 functional patterns. there are also others. these just happen to be two of the most popular. when i am helping students with nursing diagnoses i sequence using maslow. i pull out a copy of his pyramid and sequence in the order of importance as he defines them. you can get a copy of these here:
you should now know where to start--look at and list your abnormal assessment data. don't forget to read the information on the forums i linked above. care plans are like any other nursing skill. you have to do many of them before you master them. don't despair. i didn't really feel like i knew what i was doing with care plan writing until i was well out of nursing school and on the job. but you do have to put your best effort into this since a grade is probably depending on it. care plans are helping you to learn to think critically. that is something that every nurse has to be able to do on the job.
good luck! i will always gladly answer questions about nursing diagnosis and care planning. welcome to allnurses!