Hello Registered Nurse RN. Your website and Youtube videos are awesome, they are easy to follow and very helpful. I need help with care plans and am unsure where to post this to get your help, I could not find a place to ask, but if you can offer some advice for me for next week.
I have never written a care plan in my life and saw the first one here on your website. I have been an LPN for 18 years and am in school to get my RN. I have a workshop next week in preparation for my clinical exam to complete my RN and I have the Care Plan book as well as the NANDA nursing diagnosis book, but I am still having difficulty.
As a part of my exam I will have to write a care plan and provide 2 nursing diagnosis’s with 2 interventions that will be timed at 30 minutes. Is there anything you can advise on how to write a simple care plan for someone that has never done one before? I am sooo at a loss right now even though I have watched your videos, I am still unsure how I can do this in 30 minutes being that I have written a care plan before. Please advise and thank you.
Hey Rhonda! Thank you so much for your comment regarding my nursing videos and I am glad you like them, that means a lot to me. We can correspond on this thread (comment below) so I can help answer your questions. I remember having to do this same thing when I was in nursing school getting my RN degree.
Usually how it works, is that they will give you a scenario (like the ones I have with my care plans). Based on that scenario you will have to develop a nursing diagnosis. This is where your nursing diagnosis book will come in handy. The nursing diagnosis book is where you get your diagnosis (you will copy the diagnosis verbatim from the book). During the care plan part of the exam, they usually let you use your nursing care plan/diagnosis book.
So the first step you will need to do, is look at the scenario and ask yourself “What is going on with this patient that I need to take care of as the nurse”. This will help you in developing your nursing diagnosis. Think of a nursing diagnosis as 3 parts.
How to Develop a Nursing Diagnosis
A nursing diagnosis looks like this: (The patient’s problem) related to (what is causing the problem) as evidence by (the signs and symptoms the patient is presenting with). Your diagnosis book will have an index of possible diagnoses you can use. Example of a nursing diagnosis: Impaired comfort related to pruritus secondary to poison ivy as evidence by patient itching poison ivy lesions, grimacing on face, and verbalizing discomfort.
Let’s go over this care plan sample I made. In this scenario, the patient is experiencing a severe case of poison ivy and he is complaining of extreme itching. Automatically, as the nurse you should start thinking “Impaired skin integrity” or “impaired comfort”. When you are developing a diagnosis there is no right or wrong diagnosis, but you must make sure the patient “qualifies” for the diagnosis. In order to make sure they “qualify” for that diagnosis you have to make sure they meet the defining characteristics of “major and minor” symptoms listed in the nursing diagnosis book.
To help you see this, look in your nursing diagnosis book for impaired comfort and it will have listed “major” and “minor” symptoms that the patient must present with in order for you to use that specific diagnosis. In addition, it will have the related to causes and you should see in your book under impaired comfort, “pruritus” which is what I used for this specific patient.
Based on the scenario the patient meets the criteria for “impaired comfort”. Since we already have “the patient’s problem”, lets complete the related to part. This will be listed under “related factors” and it will list related to factors that you can use for your patient. In this scenario, the related to is related to pruritus secondary to poison ivy. Again if you look in your nursing diagnosis book for impaired comfort you will see how I got this “related to” part.
Now to the as evidence by which is the easiest part. This is where you will put the supporting evidence for why your patient is having impaired comfort and the reason here in this scenario is due to the patient itching poison ivy lesions, grimacing on face, and verbalizing discomfort (this was the information provided in the scenario). Now your done with your diagnosis.
Your diagnosis will read like this:
Impaired comfort related to pruritus secondary to poison ivy as evidence patient itching poison ivy lesions, grimacing on face, and verbalizing discomfort.
Developing Nursing Interventions & Patient Goals
This key with getting your nursing interventions and patient goals right is that they have to be specific and measureable. This is what your professor will be looking for on your exam. In addition, this is what you develop on your own and this is where you LPN knowledge will help you.
So with this patient, he is having “impaired comfort” and we will ask ourselves “what does this patient need to achieve so he no longer has impaired comfort?”. First, we will need to take care of his extreme itching.
A patient goal would be:
Patient will rate itching and discomfort less than a 3 on a 1-10 discomfort rating scale within 4 hours of medical treatment. (Note this goal is patient specific ((in bold)) and measureable ((underlined))
Your nursing interventions will compliment the patient goals because this is what you will do as the nurse so the patient meets their goal.
A nursing intervention would be:
Every 4 hours the nurse will assess the patient discomfort rating by using a 1-10 scale. (Note this goal is patient specific ((in bold)) and measurable ((underlined))
The hardest part is getting the diagnosis and then once you get that, the goals and interventions are easy. Remember your goals and intervention must be related to your nursing diagnosis. For instances, if your diagnosis was impaired gas exchange you wouldn’t want your goals to be about skin integrity or pain prevention.
I hope that helps clarify care plans. I don’t know which video you watched but I have included the video I made doing a care plan. After you read this, may be when you watch it again, it will help explain it even more.