Hey there friend, Christina here with nursingschoolofsuccess.com and today is a very exciting day because today
is the first day of our care plan series.
In this video, I am going to walk you through a nursing care plan template and show you
what you need to include in each section.
Of course, I'm going to break it down really easy, so you won't be confused about nursing
care plans again.
And I also have a printable care plan template to give to you, along with some sample care
plans, I'll put a link to those in the description below, so you'll definitely want to check
those out.
And of course, if you want a whole course on how to write nursing care plans, along
with more nursing care plan examples, you'll definitely want to jump into the NursingSOS
Membership Community, where we have all of that there for you.
There's a link to that in the description below as well.
Now, let's get to the video.
Okay, so the nursing care plan is broken up into 5 main sections.
And to make this super duper easy on you, it's really just the nursing process.
So the nursing process is assessment, diagnosis, planning, implementation, and evaluation.
And if you want a deep dive into the nursing process and critical thinking in nursing school,
you'll definitely want to check out the video we have on that for you.
There will be a link to that below.
So, care plans just walk you through the nursing process, so it's not that scary: assessment,
diagnosis, planning, implementation, and evaluation.
And let's walk through what you'll include in each of these sections.
So most care plans are outlined with columns like this.
And in each column you'll include one of those 5 components of the nursing process.
So, in the assessment column of the nursing care plan template, you'll write all of the
assessment data that you collected on your patient, that supports your chosen nursing
diagnosis.
So, when you go to clinical, you'll assess your patient super well, because you're a
ROCK STAR nursing student, and you'll write down all of that assessment data at clinical
so you don't forget it, and then when you get home you'll add the appropriate assessment
data to this first column.
So whatever assessment data that supports your chosen nursing diagnosis, you'll write
that down in the assessment column.
You can also divide this up into subjective and objective data.
Subjective data meaning things you can't really prove, and objective data being things you
can prove, or observe.
I've got a whole video on subjective and objective data for you, too, if you want to check that
out.
Now, the second column of the nursing care plan template is where the nursing diagnosis
goes.
This is a FULL nursing diagnosis: including the NANDA International standardized nursing
diagnosis, the related to factor, and the as evidenced by section, which is your supporting
assessment data.
So, you'll take a look at your care plan book to select the best NANDA nursing diagnosis
for your patient.
And if you don't have a care plan book, I'll put a link to my favorite one down below,
so you can check that out if you'd like.
That will be an affiliate link, so I will receive a small commission if you decide to
purchase through that link, so thanks for that, your support means the world to me!
So that's the first thing you'll do here, is to pick out the most appropriate NANDA
nursing diagnosis for your patient.
Then you'll decide what caused this problem in the first place, and this is the "related
to" part of the nursing diagnosis, the etiology.
And this should be some-how related to the pathophysiology of the disorder and what's
going on.
If you want a deeper dive into what I mean by this, you'll definitely want to check out
the How To Write Care Plans video I have for you, where I talk about that related-to section
of the nursing diagnosis in more in detail.
Now, let's talk real quick about the last part of the nursing diagnosis.
This is the as evidenced by or the "aeb" section, this is where you write AGAIN, those supporting
nursing assessment components.
So whatever evidence you gathered during your assessment that supports your nursing diagnosis,
write those down here in the as evidenced by section of the nursing diagnosis.
And now, let's move onto the planning column of the nursing care plan template.
Now, here is where things get sticky for a lot of nursing students.
This is where you write your patient goals or outcomes, so what do you want the patient
to achieve.
And you need to make sure these goals have 2 things: they need to be SMART, and they
need to be written as what the PATIENT will do.
So, SMART goals stand for specific, measurable, achievable, relevant, and time-bound.
So your goals should meet all of those points.
AND, it needs to be patient centric, meaning that it's written as what the PATIENT will
do, not the nurse.
So you'll start each goal off by writing, "The patient will..."
So these goals should be SMART, and they should be patient-centric.
Now if you need a deeper dive into the SMART goal framework for nursing care plans, you'll
want to check out that How To Write Care Plans video, where I talk about SMART goals in more
detial.
So I'll put a link to that video int he description below for you to check out.
And now let's move on to the implementation part of the nursing care plan template.
So this one has 2 parts to it: you've got the actual nursing intervention that you'll
do, and you've got the rationale for it.
So, here in this column, you'll look back and your patient goal and the related-to section
of the nursing diagnosis, and you will come up with nursing interventions that help to
fix the underlying problem, and help the patient to meet their goal.
These nursing interventions should be written as what the nurse or the NURSING STUDENT will
do.
So this isn't about the patient, this one is all about YOU.
So what are you going to do to help the patient meet their goal.
So these nursing interventions should start off with, "The nurse will..." or, "The nursing
student will..."
And then next to your nursing interventions, you'll write down why you choose each of those
nursing interventions.
This is the rationale, and it should be evidence-based, meaning that it's backed by research, and
it's been shown to work for others.
Now, friend, this is really a great place for you to stand out with your care plans,
because your instructors are going to be looking to make sure that you know what you're doing.
And this is a great place to prove it to them.
By including a solid rationale with your nursing interventions, you're showing your nursing
instructors that you know what you're talking about, and you choose those nursing interventions
for a reason.
So these rationales are really important.
And finally, we've come to the end of the nursing care plan template, which is the evaluation
column.
And this one, thankfully, is pretty straight forward.
You'll decide whether or not the patient met their goal or not, and if they didn't meet
their goal, you'll write down what you'll change in the care plan to help them meet
their goal in the future.
And if they did meet their goal, you'll come up with a new goal and do this whole process
all over again!
Fun right?
So don't worry, you can bookmark this video or save it on pinterest to come back to again
and again and again as you need it through nursing school.
I'm right here with you!
And that is the nursing care plan template and everything you'll include in your nursing
care plans.
I hope you found this video helpful, if you did, write LOVE in the comments below, I can't
wait to hear from you.
And of course, if you need more help with care plans, you'll definitely want to check
out our care plan course, and our database of sample care plans inside the NursingSOS
Membership Community.
You'll love it, it's going to save you a ton of time in nursing school to have those care
plans there for you.
So if you think that would be helpful for you, I'll pop a link down below for you to
check it out.
Thank you so much for watching friend.
Now go become the nurse that God created only YOU to be.
I'll catch you right back here next time, on the nursing school show.
Take care.