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Each week you have clinical you also have preclinical.  This means you go the day before your clinical day, pick a patient and write up a care plan.  Many people struggle with care plans.  I seem to be doing ok so far.  Like I shared with one student, the information is obvious to anyone who isn’t an idiot.  Someone has trouble breathing?  Well, maybe you shouldn’t let them walk around for too long.  Voila, a nursing diagnosis:  Ineffective breathing pattern r/t decreased energy/fatigue.

And what would a good nursing intervention be for that diagnosis?  Oh, let’s see, I dunno… maybe make sure the patient is helped from bed to toilet to chair or maybe make a small goal like walking to the end of the hallway without fatigue by hospital day 3.  See.  It’s easy.  Yes, it’s a lot of information: medical history, medications, lab values, assessment, I&O, etc.  But.  Still easy.

To give you an idea of the care plan document you turn in each week, you can click below for an example:

Care Plan Example

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