NURSING CARE PLAN TEMPLATE (PDF)

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, today I'm gonna walk you through a nursing care plan template and show you what you need to include in each section of your nursing school care plans. Of course, I'm gonna break it down really easy for you so you won't be confused about nursing care plans ever again. And I also have a PR care plan template to give you along with some sample care plans. Actually, I'll put that in a link in the description below for you, so you will definitely want to check those out. They'll help you a ton. And of course, if you want a whole course on how to write nursing school care plans, along with more nursing care plan examples, you'll definitely want to jump into the nursing SOS membership community where we've got all of that there just for you. There is a link down below in the description as well for that. Now let's get into the video. Okay, so the nursing care plan is broken up into five main sections. And to make this just super duper easy for you, it's really just the nursing process. So the nursing process is assessment, diagnosis, planning, implementation and evaluation. And if you want a deeper dive into the nursing process and critical thinking in nursing school, you will definitely want to check out that video that we've got for you on YouTube. It's there for you. I will put a link down below to that as well in the description. So care plans just walk you through that nursing process so it's not as scary. Assessment, diagnosis, planning, implementation and evaluation. And let's walk through what you'll include for each of those five sections of the care plan. So most care plans are outlined with columns, and in each column you'll include one of those five components of that nursing process, just like we outlined. So in the assessment column of the nursing care plan template, you will write all of your assessment data that you collected on your patient at clinical that supports your chosen nursing diagnosis. So when you go to clinical, you will assess your patient super well because you are a rock star nursing student, right? And then you will write down all of that assessment data at clinical so you don't forget it. And then after clinical, you'll add the appropriate assessment data to this first column here. So whatever assessment data that supports your chosen nursing diagnosis for your patient, you'll write that down in the assessment column. You can also divide this up into subjective and objective data. If you'd like to subjective data meaning things you can't really prove and objective data meaning things you can prove or you can observe. I've actually got a whole video on subjective data and objective data for you too. If you want to check that out. I will pop a link down below for that one as well. Now the second column of the Nursing Care Plan is the Nursing Diagnosis. Now this is a full nursing diagnosis including the NANDA International Standardized Nursing Diagnosis, the Related two factor and the as Evidenced by section which is their 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 will put a link down below to my favorite care plan book that you can check out. That will be an affiliate link so I will receive a small commission if you do decide to purchase through that link if you think it will be helpful for you. So thank you so much for that. Your support means the world to me. Thank you so much. So that's the first thing you'll do here is to pick out the most appropriate NANDA nursing diagnosis for your patient using your Care Plan book. Then you will decide what caused the problem in the first place. And this is that related to part of the nursing diagnosis, the etiology and this should really be somehow related to the pathophysiology of the disorder and what's going on, what's the actual cause of what's happening? If you want a deeper dive into what I mean by this, you will definitely want to check out the video we've got on how to write care plans. I've got that for you in there. I talk about the Related to section of the nursing diagnosis in a little more detail. Now let's talk real quick about the last part of this nursing diagnosis. This is the as Evidenced by section or the AEB section. This is where you write again those supporting nursing assessment components. So whatever evidence you gathered during your awesome nursing assessment at Clinical with your patient that supports your nursing diagnosis, write those down here in the as Evidenced by section of your nursing diagnosis. And now let's move into the Planning column of the Nursing Care Plan template. Now here is where things get a little 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 really have two main things. They need to be smart goals and they need to be written as what the patient will do. Smart goals stand for specific, measurable, achievable, relevant and time bound. So your goals should meet all of those points. And it also needs to be patient centric, meaning that it's written as what the patient will do, not what you, as the nursing student or the nurse will do. Start each goal off by the patient will. So these goals should be smart and they should be patient centric. Now, of course, if you want a deeper dive into the smart goal framework for nursing care plans, you will want to check out the how to Write Care Plans video that I've got for you where I do talk about these smart patient goals in a lot more detail. So I'll put a link to that in the description below along with all the other videos I've got for you. There's a lot. And now let's move on to the implementation part of the nursing care plan template. So this one also has two 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 will look back at your patient goal and the related to section of the nursing diagnosis that you created and you will come up with nursing interventions that help to fix that underlying problem, problem, the cause, and to help the patient meet their goal. These nursing interventions should be written as what the nurse or the nursing student you will do. So this is not about the patient friend. This one is all about you. So what are you going to do to help the patient meet their goals? So these nursing interventions should start with the nurse will, not the patient will, the nurse will, or the nursing student will. And then the next next to your nursing interventions, you write down why you chose each of those nursing interventions. This is the rationale and it should be evidence based, meaning that it's backed by research. It's been shown to work for other patients or the people. Now, friend, this is a really great place for you to stand out with your care plans because your instructors are really going to be looking to make sure that you know what you're doing in nursing school. And this is a great place to practice. Prove it to them by including a solid rationale for your nursing interventions. You're showing your nursing instructors that you know what you're talking about, right? And you chose those nursing interventions for a reason, on purpose, for a reason. So those rationales are really important to include there. Now, finally, we've come to the end of the nursing care plan template, which is the evaluation column. And this one, thankfully, is pretty straightforward for you. You'll dec whether or not your patient met their goal. And if they didn't meet their goal, you will write down what you'll change in their care plan to help them meet their goal in the future. And if they did meet their goal, you will come up with a brand 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 it later again and again and again as you need it. As you go through nursing school. I'm right here to do this with you. And that is the Nursing Care plan template and everything you'll need to include inside your nursing care plans for nursing school. I hope you found this video helpful, friend. 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 whole care plan course that we've got for you and the whole database of sample care plans that we've got inside of the Nursing SOS Membership community right for you. You will love it. It's gonna save you a ton of time in nursing school to have those care plans right there for you. So if you think that would be helpful, I will pop a link down below in the description for you to check out. Thank you so much for watching, friend. Now go become the nurse that God created only you to be and I will see you right back here next time on the Nursing School Show. Take care of.