How to use CarePath

This book is a working list of problem statements that describe common patient needs in plain language. Each statement has a code (a letter for the need group and a number), a short title, a type, and a one-sentence description. Use Part 1 to scan and choose; use Part 2 to read a full entry.

Types

• A (Actual): the problem is present now and can be seen or measured. The evidence is the signs and symptoms you observe.
• R (Risk): the problem has not happened yet, but risk factors are present. A risk statement is supported by risk factors, never by signs of the problem. If the signs are already present, choose the matching actual statement instead (for example, S4 Broken or damaged skin rather than S5 Likely to develop pressure sores).

The nursing process in five steps

1. Assess. Collect subjective data (what the patient or family says) and objective data (what you observe and measure).

2. Diagnose. Group the cues, find the need, and choose a statement. Check that the type (actual or risk) matches your data.

3. Plan. Set goals that are measurable: who, what change, how much, by when.

4. Implement. Carry out interventions in priority order: dangerous problems first, then comfort and teaching.

5. Evaluate. Compare findings with the goal. Was it met, partly met, or not met? Revise the plan.

Choosing between similar statements

• Nausea or vomiting: C3 (feeling sick) when there is no vomiting; F7 (vomiting) when there is, with fluid loss as the main concern.
• Pain: C1 short-term, C2 long-lasting, C8 pain near the end of life (see also D4).
• Bowel problems: E1 hard stools, E2 loose stools, E6 leakage.
• Skin: S4 damaged skin, S5 risk of pressure sores, W3 pressure sore already present.
• Falls: S1 likely to fall (the main risk statement), with M16 and B12 as contributing causes.
• Seizures: Z3 risk of seizures (the condition), S26 injury during a seizure (the safety focus).

How each Part 2 entry is arranged

Definition; causes or risk factors; signs or warning signs; a short fictional scenario in its own box with subjective (S) and objective (O) data; the CarePath diagnosis; interventions, each with a rationale (why it is done); expected outcomes; and a closing paragraph that links the data to the diagnosis. Interventions are listed in priority order. For urgent statements the first action is always to get help.

Important. All scenarios are fictional and for teaching. Vital signs, laboratory values, and targets are examples only. Real care must follow the doctor's orders, local protocols, and the patient's actual assessment.