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!
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
Measureable outcome criteria.
- Uses ranges: ____ to ____, greather than or equal to, scale, parameters
- Time frame: acute (minutes, hours, days); long term (weeks, months, years)
1. Vital signs - oximeter, cardiac monitor values, ICP, etc.
2. Body systems assessments
6. Labs/diagnostics ranges
7. Teaching learning/psychosocial
9. Other/wellness items
Broad goals. Think of Kardex. Plan for oncoming shift.
- Goal statement = opposite from nursing statement
- Never past tense - to do in the future
- Monitor, assess, perform, check, obtain, teach, follow protocols/guidelines
- Actual interventions. Usually past tense
- What care was provided for patient?
- How did you gather data to measure against your normal ranges in your outcome criteria?
- Frequency - How often did you obtain patient data?
- Each goal met/not met: Should read like you actually documented vital signs, assess, care on your patient
- Which labs/dx did you check?
- What was taught/what support measures, comfort used?
When goals not met, that justifies your need for nursing care.