Care Plan Template

[RainDreamer, BSN, RN]

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.

• 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

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.

• Goal statement = opposite from nursing statement
  
• Never past tense - to do in the future
  
• Monitor, assess, perform, check, obtain, teach, follow protocols/guidelines
  

Implementation:

• 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?
  

Evaluation:

• 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.

[abundantjoy07, RN]

Thanks so much! I'm sure I'll be putting this to good use!

[RedSox33RN]

Geez, and guess what I'M doing right now (okay, what I'm SUPPOSED to be doing)??? LOL

That will come in very handy! Thanks! :)

[micco]

thanks for the template! I am sure it will come in handy. I do have a question on the related to. I always thought that the related to could not be a medical diagnosis because that was something a nurse could not change. May be I was told wrong on that.

thank you very much for the template!!!:balloons:

[twarlik]

thanks for the template! I am sure it will come in handy. I do have a question on the related to. I always thought that the related to could not be a medical diagnosis because that was something a nurse could not change. May be I was told wrong on that.

This is what I have been told from the very beginning as well. Our diagnoses need to have a "related to" which is usually at the cellular level, and also a "secondary to", which can be a medical diagnosis. Suppose lots of instructors teach it differently.

[Achoo!, LPN]

I haven't stared yet but this looks very helpful. I printed it out anyways! Thanks :)

[RainDreamer, BSN, RN]

The actual nursing diagnosis can't be a medical diagnosis. But we can use "related to (medical diagnosis)". For example, the nursing diagnosis can't be pnuemonia, but it can be Impaired Gas Exchange related to pnuemonia. Or if you can't use a medical diagnosis as a related to, then just explain what pneumonia is or the signs/symptoms of pneumonia that the patient is experiencing.

If I use a medical diagnosis as related to, I usually include the signs and symptoms. I add more detail than just "pneumonia".

A lot of instructors do expect different things. Which is really frustrating. My first semester we couldn't use medical diagnosis anywhere in our nursing diagnosis. Now we can. Go with what you're instructor wants.

[micco]

The way I was taught was the "related to" had to be something you could change. As a nurse, you cannot change a medical diagnosis. For example, risk for impaired skin integrity r/t to immobility rather than impaired skin integrity r/t paralysis. What as a nurse can you do to change paralysis - nothing, but you can change immobility by repositioning, having patient sitting up in chair, etc. Every instructor wants things differently. even within the same school.

[RainDreamer, BSN, RN]

Bumping this up for luvnracin and anyone else that may benefit from it, it's helped me a lot in all my careplans.

[onduty23]

thanks alot doing my first semester now and we have to do several care plans

[Carlos Casteneda]

thank you

best wishes

julian

[manna, BSN, RN]

Our "related to" also could not be a medical diagnosis, but the "secondary to" can.

The "related to" is often just kind of restating the nursing diagnosis in different terms.

For example -

Impaired gas exchange r/t altered oxygen supply secondary to pneumonia