Care Plans Anyone???

[litljenarey]

As far as I know, I think everybody has to do them.

I know alot of people in my program find them really difficult, but I've really never had any problems with them. It's like math, they used to make you write out the entire problem even if you already knew the answer. Same thing...

What I usually do is take a step back, forget that you have to put this on paper and just think, "what am I doing for this patient"

okay, now you have an intervention, what made you do that?

Now you have a diagnosis. Everything else is just fill in the blanks from there.

For example (I'll use my most recent, since I just finished this care plan):
39yr old admitted four days ago DOS for a hysterectomy related to fibriods. Discharged at noon, small abdominal incision, no complications, doesn't smoke, doesn't drink, fully functioning and isn't on any meds, no dressings, no IV site. I didn't do much all day, and the patient didn't have much going on.

What did I do?
vitals signs
d/c teaching
(seriously, that is ALL I did for this patient before they went home)

why did I do these?
risk for infection (risk for, can't use)
knowledge deficit - I taught, which means she learned (objective data) her vitals signs and assesment showed a readyness to learn (objective data) STG: patient will state a understanding of discharge teaching (ie, call dr if temp over 101, no heavy lifting, etc) by end of shift. ltg: patient will demonstate intervetions listed on discharge plan by follow up visit in 1 week. unable to assess.

another one: anxiety
patient was anxious to go home...maybe my objective data relates to lack of attention, wandering eyes, gathering belongings while teaching, etc.
(I love that one, whenever a patient is in the hospital they are almost always anxious!)
then there's pain r/t abdominal incision. maybe caregiven role strain r/t physical limititations after surgery

If you don't think you have enough information, get more information. If your thinking about it when you visit the patient, you may be able to ask the right questions.

if your still having problems, try getting a better care plan book. two that I've seen that I love:
Nursing Care Plans by Doenges Moorhouse, and Geissler
Nursing diagnosis reference manual by Sparks and Taylor (this one even gives "expectations" which are goals but not quite worded the same)

I'm always happy to help, so if your struggling on a specific problem, just let me know.

[cassioo]

my students have to write 2 care plans every week for the clinical patient they had. So after a 4 week peds rotation they have 8 peds plans. After 4 weeks OB they have 4 OB and 4 nursery and 2 L&D plans. OB/Peds is our last semester so they paperwork is pretty short and sweet 3 pages 1/2 of one is for the care plans. Remember if you have a risk or potential for problem there is no AEB because if you had AEB it's a real problem. Also the 1st intervention is Assess and outcomes are measurable.

[txlynn]

Thanks Everyone. I did mine for this week, just hope they are ok for I'm running out of time. Sometimes in Drs offices It's hard for me to find a problem to do a care plan on especially when they are almost all allergy visits and seems like all my cps are the same every week. We also have different other papers to complete for our clinicals for each department.And we do drug cards on any meds we administer unless it's during out 2 week med pass.
One of my Cps was for an RSV infant, so I did "Ineffective airway clearance, RT inability to cough, AEB loud crackles in both R and L lungs.. I know it sounds lame but I think the teacher wants us to stay simple right now. When I try to get too technical I get into trouble.