Trying to do my first care plan and I am lost

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I have looked at a lot of websites trying to explain how to write care plans. I am just really lost on how to begin. This was my first week of clinicals as a nursing student. The resident I was assigned to had several medical diagnosis's(sp) but the three main ones were Hypoxic Encephalopathy d/t polysubstance abuse, CVA, and HTN.

This is where I get lost I am not looking for anyone to write the care plan for me I am just trying to figure out how to get started.

the pt needs total care, is a tube feeder, G-tube to be precise and is on several med for agitation.

TIA,

Crystal

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Specializes in LTC.

Today I received feedback from my instructor based on my first care plan... here were a few suggestions she made to me, maybe this will help: She advised me to List as many nursing actions/interventions as possible. She also encouraged me to know and understand how lab data corresponds with the pts. Clinical manifestations. She told me that I was strong in writing the etilogy and pathophysiology... Just make sure you include lots of detail in that. I would also suggest getting your class mates to review your care plan before you turn it in. I heard that it is helpful to get a careplan book... I plan on getting one ASAP, so I can use it for my first care plan. I was also really nervous about my first care plan... I was totally shocked when she pointed out my strong areas, and not surprised to see red all over my paper ! My instructor gave me great constructive critism so that I can improve my care plans as I progress through nursing school and my career.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

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:

you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).

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.

[*]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.

[*]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:

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Specializes in HOSPICE.

YOU ALWAYS DO SUCH A GOOD JOB AT HELPING US "NEWBYS":bow:

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Specializes in none.

If its any consolation, I am a nursing student now and so far have done approx 8 care plans and feel myself improving but my first was like going out into the woods to hunt for dinner and just shooting at anything ,hoping that you catch something good for dinner! --Lost is exactly right but take heart --your instructors will give you needed pointers and not leave you to fend for yourself....good luck to you!

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