Nursing Care Plan Template

Daytonite, BSN, RN · Jun 26, 2008

The nursing home I worked in some years ago had a one page template for a care plan similar to the one on RN Central's site. It is very simple. I've attached it below. The column for the "Problem" can either be a symptom or a nursing diagnosis depending on what your facility wants you to use.

What specifically are you wanting? One of the things I do in my spare time is create forms.

LTC Care Plan Template.doc

Acute POC for Diarrhea.doc

lpn311 · Jun 26, 2008

Thanks so much :up:

I work in the HIV/AIDS department at the American Red Cross, and the care plan doesnt have to be a specific kind, but I liked the one I had. The one you sent is awesome too, so I saved it, thank you very much! the Dx's are different for each client and they vary d/t OI's and most of the time its multiple Dx's so we do it a bit differently than normal care plans--well the care plans i was used to doing 12 years ago when i started my nursing career lol! I love my job now, its more social nursing and med adherence ....... I am also the Life Skills Advocate too so its alot of teaching, planning, and assisting with ADL's. Most of my days I f/u with phone calls, do some intakes and assessments, some care plans and my nursing notes....some coding and fililng...right now I have no clients today so I am on here learning. Even on the slow days I still love my job :redbeathe

Daytonite, BSN, RN · Jun 27, 2008

In the old days, ha ha, I'm talking about the 70's, we used to list what you would call symptoms today as the patient problems. It was in the late 70's when a bunch of nurses decided that they were tired of writing the same nursing interventions for certain symptoms so, light bulb please, why not group those symptoms together and stick a name (label) on them. That's how nursing diagnosis came about. But we used to write vomiting, diarrhea, coughing, edema and symptoms like that as "problems" on our care plan templates all the time before nursing diagnoses came into being.

You can do a nursing care plan any way you want unless the facility says you have to do it a specific way. I've had these ones from the nursing home for 10 years. The language on them is old. When I first saw them I asked who had originally written them. No one remembered or knew. But the ones that I added I wrote up in the same style. I have these short one page care plans for

Lung Congestion/CHF
Low H&H and Low Grade Fever
Skin Tear
Seizures
Shingles (Herpes Zoster)
Skin Laceration
Post Bone Marrow Aspiration
Post-op Cataract Removal

These are just the ones that were saved because I had printed them out. A whole bunch more were lost when the hard drive of my lap top was erased by a technician repairing my computer. If you are interested in any of them, let me know and I'll share them with you.