Nursing Care Plan Sample

Guidelines

1. The purpose of a nursing care plan is to identify problems of a patient and find solutions to the problems. This is done in five steps: assessment, diagnosis, planning, intervention, and evaluation. All five of these steps must be complete in order to have a true care plan.

2. The diagnosis column will include some assessment data. Ask yourself, "why did I choose this particular diagnosis?" The answer should lie in the assessment data. Your diagnosis should read: nursing diagnosis.. related to... as evidenced by.... The "as evidenced by" (AEB) should include your assessment data of how you decided on that particular diagnosis. The "related to" is often part of the medical diagnosis.

3. The planning column is really a goal column. Here is where you put what you would like to see from the patient by the end of your shift, clinical week or whatever your timeframe is. The most important thing about your goals is that you must make them MEASURABLE. Use numbers where possible. Stay away from words like "a decrease in, an increase in, to look somewhat better, etc." Your evaluation should include exactly what the changes were. They should also be verifiable by someone else. For example, if your patient is in pain and rates his pain as an 8 on a scale of 1-10 and you want him, by the end of the day, to rate it as a 3. Or, patient will walk around nurses station 3 times by the end of the shift. How many times? Three! This is a very measurable goal that another person could verify. Remember, measurable, measurable, measurable!

4. Your interventions should be appropriate to help solve the problem. Your book has many sample nursing care plans. Take a look through them to get some ideas about nursing interventions. Some that you use will be tried and true ones that nurses have been using forever. Others may be from your own imagination. As long as they will help your patient to achieve his or her goals, they are worth doing! Think about looking at old photographs of family with your patients to help them to take their minds off of what is happening to them. Maybe you could watch TV with your patient and just spend some time with them. Be creative!

5. You'll need to include scientific rationale for each intervention. You can usually find these in your Harkreader and occasionally in your Lemone book. The question here is, "why are we using this particular intervention?" Be sure to line up your interventions with your scientific rationale when you are writing them so that it will be easy to understand.

6. The evaluation column will not be filled out until after you have completed your interventions. The question here is, "was my goal accomplished? Why or why not?" You may not always achieve your goals. That's OK. If you didn't, why not? Was the goal unrealistic for this patient? Was the patient out of the room most of the day? Did he just refuse your interventions? The lesson here is to learn what works best with different types of patients so that you can better take care of the next patient down the line with the same problems. You are building something like a "database" in your head regarding nursing care. Sometimes, the same interventions won't work on the same kinds of patients. Again, this is a learning experience for you.

7. One important thing to do in the mornings (or afternoons) when you are first talking to your patient is to let them know what the plan of care for the day is going to be. This will be a very abbreviated version of your care plan. Let them know what you want to see them accomplish for the day and how together you can accomplish it. Remember that even the best care plan is useless unless the patient also believes in the same goals.