LEGAL NOTICE TO THE FOLLOWING ALLNURSES SUBSCRIBERS: Pixie.RN, JustBeachyNurse, monkeyhq, duskyjewel, and LadyFree28. An Order has been issued by the United States District Court for the District of Minnesota that affects you in the case EAST COAST TEST PREP LLC v. ALLNURSES.COM, INC. Click here for more information
There are any number of care plan books out there. Go to the bookstore (online or hard-copy) or the library and look over a few if your faculty hasn't assigned you one or hasn't given you a template they want you to follow. Ask them, too.
The basic elements are:
Subjective: What does the patient tell you about what's happening?
Objective: What are your observations/chart findings/measurements that relate to the possible problem?
Assessment: What do you think is going on and why? (That's your nursing diagnosis with rationales)
Plan: What are your nursing interventions going to be, and how will you reassess how they work?
Another way to look at this is ADPIE: Assessment, Diagnosis, Plan, Intervention, Evaluation, which would include all of the above