Please Help! I don't know where to start c this care plan

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hello everyone, i am a new pn student in illinois, and our program is a bit disorganized, hence this post. my clinical group is scheduled in the evening at a very nice private catholic-based home from 4:30 to 8:30pm, which at this time all the residents are eating in the dining area and then off to bed. meaning, us pn students aren't really doing jack:mad:. we assist in feeding if need be, but other than that, there is no real hands on experience with the residents/patients. so our clinical instructor tries the best she can to make the best of it all. she has us practice on each other vitals or quizzes us on critical thinking questions, but most of all -jot down info from the pts record to use for our care plan.

now, our theory courses aren't exactly correlating with the clinical courses, so that's why i'm asking -how do i do this care plan? i am not asking that you do this for me, but please give me a boost, because i am not sure where the h-e-double-hockey-stick to start:o. all i ask is that you please answer my bold question instead of commenting on my disorganized program. i only discussed it because i know that there are going to be a million questions as to why i wouldn't know this, etc.

here is the info i jotted down exactly the way it is in pts record (if you know what these abbreviations are, please, do tell):

pt: female, 92

incontinent, bowel & bladder

dx:

chest wall pain/sacral decubitus ulcer/weakness/frequent falls/poor appetite/tia/htn/ca skin face

no known allergy

thank you so much!

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Hello Jessi,

pt: patient, Dx: diagnosis, HTN: hypertension for what I know.

For your care plan how far are you guys suppose to go for fundamentals?

in my program, for the first rotation, our care plan consisted of demographics (name, age, gender, marital status, primary caregiver, religion, responsible party... any pertinent information related to the patient). in section 2, we had to talk about medical conditions and pathophysiology of each; i.e pick 2 or 3 diseases out and present their process(definition, etiology, signs and symptoms, treatment, prognosis...). For the second rotation, since we will be passing meds, we will have to add a third section related to those medications and their effects.

I hope this helps.

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Specializes in Pediatrics, OB/GYN, ER, Geriatrics.

CA Skin Face: Cancer

TIA: Transient ischemic attack (stroke)

I agree with nursetobe745, in fundamentals we had to do care plans with the pt demigraphics, pick a medical condition and list etiology, pathophysiology and definition of disease/condition. Then we have to come up with 5 interventions, 5 nursing Dx's, outcomes, rationales for the Dx's. We had to list and look up all the meds the pt was taking and list side effects, how administered, ect.

I would take one of the disease/disorders you are interested in learning more about and formulate a care plan out of that for this pt. That is the best solution I can come up with.

HTH!

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I appreciate your responses, but they still don't answer my question. My instructor informed me that she wanted me to do my care plan on Chest Wall Pain. I'm just totally stumped on how to write this out as far as Assessment, Planning, Implementation, & Evaluation. It just seems like such a broad diagnosis, and I and the instructor looked all through this client's record and it's not too detailed. :crying2:

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Specializes in Pediatrics, OB/GYN, ER, Geriatrics.

Try googling "care plan for chest wall pain" and see what comes up. Other than buying or looking through a care plan book, I do not know what else to suggest as far as formulating this.

First and foremost, you need the reason (etiology) for the pain and then go from there.

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okay hey I hope Im not too late in helping with this, we also just started care plans so here is a sample (please don't copy it word for word the teacher will know) of a nursing care plan focused on the chest pain. )it's number 3) http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25166/6442700.cw/content/index.html

good luck and let me know how it turned out

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THANK YOU ALL FOR RESPONDING! I TRULY APPRECIATE YOUR HELP! I and my class as well, are in a lil' dilemma with this pn program -our instructors don't communicate with each other, it's really ridiculous, then the students are talked down to like their !@#$%*& -ups are our faults. In our Perspectives course (ethics, law, nursing act, critical thinking, care plan, etc.) the instructor is teaching us the care planning in this format:

ASSESSMENT (what you see), PLANNING (goal), IMPLEMENTATION (what you did for pt, and this instructor states that implentation is the exact same as INTERVENTION), and EVALUATION (did the plan work).

Our clinical instructor (whom I am doing the Chest Wall Pain care plan for), wants our class to do the care plan in this format:

PROBLEM (need), OBJECTIVES (goals), INTERVENTION (do), IMPLEMENTATION (did), and EVALUATION

And according to our clinical instructor, the Perspective instructor "should know better" and "is teaching you all wrong". So whichever the case may be, my current care plan assignment needs to be set-up with the 5 columns instead of 4 (the clinical instructor's way).

I would have stated this earlier, but after working long and hard on my care plan the way the Perspectives instructor had taught us, my clinical instructor didn't accept, and explained she wanted it as mentioned above. Our class is very frustrated to say the least. But regardless, I am still asking for help, because Intervention & Implementation seem the same to me. -I'm just....I'm just confused :eek:. Please help :crying2:

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