How do you formulate a care plan?

[Robert F]

I am interested to see what kind of things you guys take into account when writing a care plan. What areas are important to you and why? Do you stick with a specific set of generalized goals based on the textbook or do you set your own based on the individual patient rather than his/her condition as a whole?

For instance, I like to promote autonomy in my cardiac patients and like to get them up and about when they can handle it. I also take into account the medications my patient is on whenever I decide what kind of diet they need to be on.

One example would be adjusting the diet of a patient who is on a potassium wasting or sparing diuretic such as lasix or spironolactone and getting a BMP to keep up with their K+ levels. Another thing would be my initial treatments such as the use of sodium chloride in the hyponatremic patient as the chlorides will break off and the sodium ions will typically bind.

There are lots of things that can be taken into consideration in care plans. What better way to understand pathophysiology than to map out a care plan based on how one system can affect another.

[cougarnurse]

Have done the generalized ones, and 'tweaked' them to fit the individual. Gets interesting!

[RNCMSN]

Well in today's world, the care plan should consist of the individual needs of the pt. Any experienced nurse can map a plan of care for the physiological problems identified. I agree with Cat. Tweaking the care plan makes it interesting and will address the needs of the person as whole. you know, that mind, body, spirit thing.

[orionseal]

I try to put as moch for spiritual health as I can without getting too much flack from co-workers for it this can get a little confusing when it comes to wording it just rite, I am a firm believer in the fact that medicine can only do so much and the rest is up to the patient.

I did recover from a broken neck after all, with a 40/60 chance against ever walking again. and here I am. For all that, I get blank stares when people ask me about how I got the scars on the back of my neck, some don't believe me, but thats OK.

If you believe you will recover then your chances are beter than if you don't believe. Instilling hope in people (not false hope, I know when to draw the line) is a big part of the recovery prosses.