Teaching Patient Care Plan??

Daytonite, BSN, RN · Nov 3, 2008

you start like you do for any care plan. . .

assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)

a physical assessment of the patient
assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
- use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

care planning is determining what the patient's problems are. in this case, you specifically know you want to focus on his nutrition. so, you need to do an assessment of his diet and nutritional state. i have no specific assessment guide for that, but i assume you do. you are looking for abnormal data because the abnormal data will become the evidence that will support the nursing diagnosis that you will use.

determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

your instructors might have given it to you.
you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
- http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
- http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

there are three ways to introduce teaching interventions. either through a diagnosis that focuses on the patient's nutritional problem, using the deficient knowledge, specify diagnosis or ineffective health maintenance diagnosis. each diagnosis has different etiology and evidence to support it. i suggest that the patient's attitude toward this will have a strong affect on which diagnosis you end up using out of the three and how your teaching plan will be focused.

a formal written teaching plan has these components:

overview: a synopsis about what is going to be taught in the course
goal(s): the aim(s) or outcome(s) that you want your learner to achieve as a result of the lesson you plan
objectives: the more specific information that the learner will come away from the course knowing that will achieve the goal(s) you have determined.
content: a play-by-play of the specific content that is going to be taught and in the sequence it will happen. your content should address and cover all the objectives. this part of the written lesson plan is presented in an outline format.
procedures and materials: how all the above will be achieved, i.e. lecture, demonstration, discussion, etc. materials that can be used and resources that can be needed for the lesson to be successful and essential to teaching your lesson plan are listed and may include demonstrations, audio-visuals, handouts, experiments, stories, game playing and any number of other creative items.
evaluation: determining if you met the goals of the teaching plan. this can be done through a return demonstration, short post test, short question and return answer session with the client to verify they understand the information correctly or a task the participant needs to perform.

for more information on care planning, see https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans