Pulling my hair out!! Need HELP! Please!!

[kwagner_51]

I am struggling with Care Plans and it's really starting to p*** me off! The instructor I had last semester was new and young and not very strict. NO ONE explained to us exactly what to put on a care plan. Oh, they mentioned PES and Goals, outcomes, evaluations, etc. BUT they never really explained how to write one. We were left to 'wing it'.

I did my first CP this semester on Pyloric Stenosis on a newborn. Even tho I did plenty of CP's in the Fall semester, I didn't do this one right!!

I got an 80% [which is passing] because she felt sorry for us!!

I had all the diagnostic labs for blood at the newborn levels and made up what the infant's would be if she actually had PS. She asked if the values were for adults!!

I only had 2 nursing diagnosis, on the real baby and I should have had 5-6. On the PS CP, I had 6 Nursing interventions and 3 General Nursing care guidelines listed. I keep messing up the Goals.

For my goal for PS I put: Pt. will have no vomiting, by D/C. Pt. will meet body requirements within 3 weeks of d/c.

For the PES I put: High risk for dehydration R/T projectile vomiting.

Also, Altered Nutrition; less than body requirements R/T projectile vomiting AEB: FTT.

My real pt. was healthy as a horse and so there was no real CP needed, other than teaching.

Is there someplace on the web that teaches how to do care plans? I have Mosby's Nursing Care Plans, Nursing Diagnosis and Intervention. However, it is for M/S and not OB/NB PP GYN.

Any help would be greatly appreciated!!

[kc ccurn]

I think a great resource for you would be your instructor. Let her know that you are having a difficult time and would like some suggestions. She will see that you are making an effort and are interested in learning. That will come in handy down the road! In nursing school, students are afraid of going to their instructors for help, IMO. Well, that's their job, that's why they are there, is to help you learn. They can be an invaluable resource-use them.

[happystudent, RN]

hey there!

Now our CP are set up as follows:

Nu DX:

Goals:

Intervention/rational:

Evaulation/outcome:

Example: Nudx: Knowledge deficit: AEB pt stating"I dont know what risperadol will do to me"

Goal: Pt will verbalize what Classification risperadol is and what it is prescribed for

INtervention: Go over medication with the pt using drug guide

Rational/ Pt will have accurate information and trust the source.

Give pt pamphlets with information about the drug// This provides a resource for the pt if she needs to remind herself of drug interactions

Evaluation: Pt states" I understand that risperadol is an antipsychotic that stops the bad thoughts and it takes a week to build up in my system"

Goal met.

This is just a brief summary of my care plan on a psych pt. The outcome always matches what your intended goal is.

Your goal should be measurable unless it is a teaching goal. In that case you use the pts statements.

If your pt doent meet the outcome, just state it.

Hope this helps!