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: