"Care Plans": The Basics
Different schools have different Care Plan formats and they use them in various ways. Sometimes Care Plans are employed to teach pathophysiology. Other times they may be used to assess your writing skill and knowledge of APA format. But without the core elements of clinical reasoning, those assignments are just another homework exercise. Therefore, rather than attempting to discuss something highly variable (care planning), our focus will be on that which is much more absolute... the nursing process.(a.k.a. clinical logic/reasoning.)
1. Focused assessment
This step in the nursing process can be summed up in two sentences. First: you cannot know too much about your patient. Second: you cannot plan care in a fact-free zone. If you are writing care plans, you've probably learned how to interview and examine a patient. The concept of assessment, however, is incredibly broad. It involves almost every part of the patient's record, medications the patient is taking (and your knowledge of therapeutic and side effects of the drugs), diagnostic studies, laboratory values, observations about family dynamics and much, much more. The purpose of this website is not to teach assessment skills, but to demonstrate how all data you collect can be sifted and culled (i.e., focused) to determine your patients' priority problems and to articulate them succinctly.
2. Problem statement (a.k.a. Nursing diagnosis)
As will be discussed later, the term "Nursing Diagnosis" is highly associated with an organization (NANDA-I). To avoid confusion, this web site will use the term "problem statement". Functionally, however, to state the patient's problem is to make a diagnosis. Clearly articulating the patient's priority problem(s) requires a syntax that has three parts. First, the problem itself. Second, the cause of the problem. And last, the evidence that suggests the problem exists. FOR EXAMPLE...
Every Labor Day weekend, there is a festival in the Black Rock desert of Nevada called Burning Man. Tens of thousands of enthusiasts gather in the sun and grit to do interesting things, often involving intoxicants. Not uncommonly, ill-prepared people find themselves suddenly sober and stranded in an area of desiccated earth some distance from where they began wandering. When they are eventually located, they are taken to the "nearest" hospital and invariably found to be severely dehydrated. The nurse caring for these patients would comprehend the problem/nursing diagnosis in this syntax:
Impaired fluid balance (dehydration) related to (RT) grossly inadequate intake and outrageous insensible loss as evidenced by (AEB) serum Na+ 158, BUN 50, Creatinine 2.4, and scant amount of dark urine in bladder when catheterized.
And though bedside nurses may not write this convoluted stuff down in "care plans", their report at shift change would be remarkably similar to what you've just read above.
Impaired fluid balance (dehydration) related to (RT) grossly inadequate intake and outrageous insensible loss as evidenced by (AEB) serum Na+ 158, BUN 50, Creatinine 2.4, and scant amount of dark urine in bladder when catheterized.
And though bedside nurses may not write this convoluted stuff down in "care plans", their report at shift change would be remarkably similar to what you've just read above.