Practicing nursing care plans

x_factor · Dec 14, 2011

I am so glad you posted that NANDA book recommendation GrnTea, thanks a bunch! I'm going to pick up a copy today on Amazon and start getting a headstart while on winter break.

williams3929 · Dec 30, 2011

Just remember that everything in your care plan should fit together like a puzzle and your diagnosis statement is the glue that holds it together...The only data that should be in the assessment is the information relevant to the diagnosis statement...Oh and your care plan should be individualized to the client...Your outcomes should be realistic, measurable, have a time frame and be client oriented(Client will)...Oh and cite everything... Try these sentences

My client has (dx)

Because of (r/t)defining characteristics

I can tell because (S/S)AEB

nurseprnRN, BSN, RN · Dec 30, 2011

i have often said that "related to" and "as evidenced by" should not be part of the new students' program, because they need to get the idea better than the big words. as williams3929 says above, using short english words to teach and use this would be so much more helpful.

examples:

(risk-for diagnosis)

my patient's nursing diagnosis is "risk for infection (domain 11, safety/protection;class 1, infection)," because he has diabetes, two invasive lines, a foley, and very low serum proteins.

(not a risk-for diagnosis)

my patient's nursing diagnosis is, "impaired physical mobility (domain 4, activity/rest; class 2, activity/exercise)," i know this because he becomes short of breath walking from his bed to the chair, because he has decreased endurance..

or

my patient's nursing diagnosis is, "impaired physical mobility (domain 4, activity/rest; class 2, activity/exercise)," i know this because she engages in substitutions for movement such as increased attention to others' activity, controlling behavior, and focus on pre-illness disability/activity, because she is very anxious.

or

my patient's nursing diagnosis is, "impaired urinary elimination (domain 3, elimination and exchange; class 1, urinary function)," i know this because she has dysuria, urgency, and frequency because she has a urinary tract infection.

NCRNMDM, ASN, RN · Dec 30, 2011

A NANDA book is a must have. I have both a NANDA book and the book All In One Care Planning Resource. I use the NANDA text much more often than the other, but sometimes using both is necessary. The Care Planning Resource is more of a breakdown of how to write a care plan, and it offers suggested interventions and the rationales behind them. I find the NANDA to be more helpful now, as I've spent a semester writing care plans, and I feel like I understand the interventions, their rationales, and why I would choose certain interventions over others. To be perfectly honest, writing care plans is really a trial by fire kind of thing. You have to start writing them, and making mistakes, before you improve at all. Our class had to write a practice care plan in class prior to beginning clinical, and I'm so glad we did. My first care plan, while very thorough, wasn't patient directed at all. Rather than focusing on my assessment, I focused on the medical data I was reading from the chart, as well as the patient's past history from the chart. As a result, my care plan addressed the patient's chronic health issues, like diabetes, CHF, etc, but failed to address the main concerns (pelvic fracture, sepsis, and hypokalemia).

When you take care of your first patient, assess them thoroughly. Assess for issues caused by their current medical problems, but also assess for potential risks. Are they at a risk for infection because of their IV lines, catheter, recent surgical procedure, etc? Are they at a risk for falls because of their preexisting confusion and sedation from opioid pain medications? Are they at a risk for constipation because of their opioid pain medications and NPO diet? Base your care plan on the assessment that you did, and the data that you gathered. Address the current issues the patient has, not issues that the chart indicates they had three years ago (unless it's a chronic issue that is now playing into their admission). Address what you observed and noted during your assessment. If you base your care plan on your assessment, you will find that it is much easier to complete. Also, keep in mind that the patient's laboratory work can also be important in the assessment. Is their potassium high or low? Is the sodium out of whack? Are they ABG values a mess? If so, why? And what diagnoses might you make based on this data? Include information from the laboratory work and your assessment, and you will have a bigger, more complete, picture of what is happening to the patient.

Care plans don't come out perfect on the first try. Don't expect that you will write an award winning plan of care on your first attempt. Like most other things in life, you have to practice to become proficient at care plans. As you progress through the semester, and the nursing program, you will become more comfortable with care plans and nursing diagnoses. Good luck!

williams3929 · Dec 30, 2011

Thanks...Those sentences my instructors told us and they really helped me to understand what the diagnosis statement was, its importance, and its structure.

nurseprnRN, BSN, RN · Dec 31, 2011

@mattrnstudent23: if you are still or were recently a student, kudos to your program. :yeah:

NCRNMDM, ASN, RN · Dec 31, 2011

I am still a student. I go to a community college program in North Carolina. I am a second semester student, and hope to pursue critical care nursing after graduation. Although it is small, my program is exceptional, and has a 99% NCLEX pass rate on the first attempt. I feel very fortunate to have gotten into such a great program. Thank you for your kinds words.

SuperStarRN · Dec 31, 2011

Also look for the book on ebay and half.com as they are usually even cheaper than amazon.