Trying to do my first care plan and I am lost

a care plan is a determination of a patient's nursing problems (phrased as nursing diagnoses) and the strategies to do something about them (nursing interventions). the way a care plan is constructed and put together from scratch is based upon a tool called the nursing process which has actually been adapted from a problem solving method that is commonly used by scientists. the nursing process consists of 5 steps and if they are followed in their established sequence, good rational solutions result. of course, you must also know the principles of nursing and other information.

this is how the nursing process (problem solving) works when applied to a common everyday situation:

this is how you apply it to a patient when you are care planning:

1. 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
       

[*]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
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

you begin this care plan by sitting down and completing your assessment of this patient. you should have done a physical assessment as well as collected information from the chart. now, you need to find out more about the medical diagnoses, their medical treatment, complications, why the patient is getting those medications for agitation and what their potential side effects are, why the patient has a g-tube and is being fed this way and what exact nursing care is being done for the patient (total care is too general a term). you can find information about encephalopathies, cva and htn on the websites listed on the medical disease information/treatment/procedures/test reference websites thread. i recommend using the merck manual or medline plus.

step 1 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

• hypoxic encephalopathy d/t polysubstance abuse
  
• cva
  
• htn
  
• medical treatments:
  • g-tube
    
  • medications for agitation

step #2 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

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem

you can see examples of help that was given to other students on this thread:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans