One of my instructors gave us this template and it has helped me tremendously when writing up my careplans. Just thought I would post this since it's helped me .... maybe some of yall can benefit from it too!
Nursing Diagnoses: Reason patient required care of nurse.
1. NANDA statement: most instructors look for actual (rather than 'risk for') when patient is in the hospital
2. Related to: related to usually medical diagnosis or major signs/symptoms
3. As evidenced by: assess or evaluate data which supports nursing diagnosis
Patient Outcomes: Measureable outcome criteria.
1. Vital signs - oximeter, cardiac monitor values, ICP, etc.
2. Body systems assessments
3. Pain
4. Nutrition/Fluids
5. Meds
6. Labs/diagnostics ranges
7. Teaching learning/psychosocial
8. ADL's
9. Other/wellness items
Planning: Broad goals. Think of Kardex. Plan for oncoming shift.
Implementation:
Evaluation:
When goals not met, that justifies your need for nursing care.