Care Plan Template

[RainDreamer]

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.

[mariedoreen]

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.

Same here, for us it would be skin integrity related to immobility secondary to paralysis.. Which reminds me, I have a big one to get done tomorrow morning... Thanks for your template info!

[RainDreamer, BSN, RN]

Yall are welcome.

And yeah, just change it according to what your instructors want. First semester we couldn't use related to "med diagnosis" but last semester we could, it's just dependent on what different instructors want, so just change accordingly.

Happy Careplanning to us all this semester!