The document provides information and guidance to nursing students on how to write a care plan, including defining the different components such as nursing diagnosis, goals, interventions, and evaluation. It explains each section in detail and provides examples. Resources are also included to help students understand and complete their care plan assignments.

1. By
Beverly Wade

2.  You too can survive nursing school!!!!!!!!!!!!!!!!!
"http://www.youtube
.com/embed/PgvVTX
hHz58

3.  What is a care plan
 Why do nurse write care plans
 What are the different parts of a care plan
 What other paper work will I need to know
 How am I evaluated
 When is everything due

4.  Provide a direction for individualized patient
care.
 Provide continuity of care for the patient with
all hospital departments.
 Provide documentation on patient and family
needs.

5.  Provides acuity for staffing needs.
 Provides reimbursement for insurance which
was started by Medicare and Medicaid and
now used by all insurance companies. This is
how hospitals and patients receive payment.
 http://youtu.be/Ll3uipTO-4A

6.  Actual—What is actually wrong with the
patient.
 Psychosocial- Nursing Process and
Self‐Concept
Related NANDA Nursing Diagnoses
 • Ineffective Role Performance
 • Body Image Disturbance
 • Chronic low self‐esteem
 • Self‐esteem disturbance
 • Situational low self‐esteem
 • Personal Identity disturbance

7. Related NANDA Nursing Diagnoses
 • Ineffective Role Performance
 • Body Image Disturbance
 • Chronic low self‐esteem
 • Self‐esteem disturbance
 • Situational low self‐esteem
 • Personal Identity disturbance

8.  What is your patient at risk for based on their
nursing diagnosis.
 Nursing diagnoses that are in the "risk for"
categories may not need the AEB portion of
the statement, since there is no actual evidence.
However, you should avoid using too many
"risk for" diagnosis. One or two, out of eight to
ten, is acceptable.
 http://www.atrane.org Link to site

9.  Nursing diagnosis
 Goals for patient and family
 Nursing care
 Nursing scientific rational
 Evaluation

10.  Begin with a complete assessment of your
patient. Get as much information as possible
from the chart, such as lab data, x-ray reports,
physician history and physical exam

11.  Subjective-This is what your patient tells
you.
― My head hurts‖ States on scale of 1-10 My
head hurts at 8.
Objective- This is what you see.
Patient rubbing head.

12.  This helps you decide what is really wrong
with your patient. You must listen to know
what they are not telling you.

13. BMP
Na L124 136-145 mEq/L
K H5.8 3.5-5.1 mEq/L
CO2 25 23-29 mEq/L
Cl 101 98-107 mEq/L
Glucose H107 74-100 mg/dL
Ca 10.1 8.6-10.2 mg/dL
BUN 17 8-23 mg/dL
Creatinine 0.9 0.8-1.3 mg/dL
Key: L=Abnormal Low, H=Abnormal High, WNL=Within Normal Limits, *=critical
value
--------------------------------------------------------------------------------
Specimen(s) Collected: 2/10/08 14:30 Lab Acc'n No. 223457
Specimen: Blood Date Reported: 2/10/08 15:30
Test Name Patient's Results Ref. Range Units
HGB L7.0* 14.0-18.0 gm/dL
HCT L21.1 42.0-52.0 %
Comment: Hgb of 7.0 and Hct of 21.1 reported to Dr. J Smith at 15:15 on 2/10/08 by J.
Doe
Date Reported: 2/10/08 18:40
HGB A1c

14.  It is not a medical diagnosis
 A nursing diagnosis is the plan of care for your
patient which all member of the staff will
follow as they care for the patient.

15.  The nursing diagnosis – From NANDA-1 list
 ―Related To‖ (R/T)- what is causing the
nursing diagnosis.
 Defining Characteristics- ―AEB‖ ( as
evidenced by) signs and symptoms better
known as subjective and objective data

16.  A goal is what you want your patient to
achieve. I has to be measureable with a
time frame noted.
 An example is:
 You will graduate in 3
 Semesters

17.  Must be : Patient centered
 Clear and concise
 Observable and measurable
 time limited
 Realistic
 one behavior /goal
 determined by patient, family, nurse
together.

18. MEASURABLE NON -MEASURABLE
 Identify
 Describe
 Perform  Know
 Relate
 State  Understand
 List
 Verbalize  Appreciate
 Demonstrate
 Share  Think
 Express
 Communicate  Accept
 Exercise
 Cough  Feel
 Walk
 Stand
 Sit
 Discuss
 Has an increase in
 Has a decrease in
 Has an absence of

19.  What are you going to do to help your patient
reach their goal. This is what you do daily for
your patient. If you give your paper to a peer
would they be able to follow your intervention
or plan of care.
http://www.youtube.com/watch?v=xRFIDg9BP
nQ
Example: If you study hard then you will
graduate

20.  This is the scientific reason you did this for
your patient. You must tell us (cite) where you
got your information. This could be your from
your books or a reliable internet source.
I studied and went to class. I sat on the front
row and took notes.

21. Poor Procrastination
On
Attendance Assignments
Failing To Take Notes
Negative or
thoughts Following teacher
instructions
Poor time
management

22.  Did your patient reach their goal in the time
frame that you allowed for them
 Did your patient not reach their goal and do
you need to extend the timeframe or is this an
unreachable goal and you need to start over?
Student passed in 3 semesters and met goals
Student did not pass in 3 semesters and goal
not met.

23. EYEBALL SHEET

24.  We have covered every aspect of this paper

25.  This is the form you will turn in daily and it
will help you write your care plan

26.  This form will be given to you on Friday after
clinical. If your instructor is very busy, you
will receive it on Monday.

27. http://www.youtube.com/watch?v=onnoPvwJ8S
M&feature=plcp

28. Nursing
Diagnosis
using
subjective and
objective
Data
Nursing
rational
and
evidence
E valuation
met
Or
not

29.  What is a care plan?
 What is a nursing diagnosis
 What is a rational
 What is an evaluations
 What is an intervention
 How long is an intervention
 How long is a goal

30. NURSING CARE PLANS
STUDENT____________________________________PATIENT INITIALS____________ROOM NUMBER__________DATES________________
ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
(supportive data) (patient's need) (nursing care needed) (documentation of care) (status of goal)
FACTUAL DATA PROBLEM STATEMENT NURSING PLAN FOR PROBLEM DOCUMENTATION STATUS OF THE GOAL
Supports your problem. This This is the name you give the Ask yourself, “What can I do for Ask, “What will I document?” Ask yourself, “Did I
information has to be problem. Ask yourself, the problem?” Any information that pertains to accomplish my goal?”
current, or perhaps past “What is the problem?” the problem. 1. Look at your goal & ask
history and NOT “make You can use the NANDA list These are not to be numbered. yourself a question related
believe”. Think of it as of problem statements OR if This is your actual narrative to it - whether your Goal
charting notes just like on your was met completely, met
supportive data that proves none apply, make a problem Think about the following:
Assessment Sheet in Level 1 or partially, or not met at all.
you have an actual or statement using one of the Observations you make related to Write this down.
potential problem. It must words: this problem, (include assess- charted observations in the nurses
notes in the chart. NOTE: This is 2. Answer the question in a
have at least 2 pieces of Alteration Impaired ment of the pt re: to the body Summarized Evaluation
NOT a restatement of your plan in the
information to support Deficit Ineffective system re: this problem, diag- past tense! Also it DOES NOT have to Statement and relate it to
problem. Dysfunction Intolerance nostic tests, and reporting of address each part of the plan. DO the M easurable Part of the
Excess findings to charge nurse. (Use NOT number this section or leave Goal. Write this down.
Ask yourself, “Why do I your senses).
spaces. Also any conclusions, or 3. Does the problem or
think this is a problem?” Refrain from using: Tasks you can do (things you can judgments that are improper in potential for the problem
Decreased Cardiac Output* do to prevent, repair, or reduce still exist? Write this down.
Disuse Syndrome
charting are not proper here.
Think about your pt’s: the problem). This includes Students have best results in 4. Then, state if you will
Impaired Gas Exchange* Continue with your plan -
1. Medical Diagnoses Impaired Physical Mobility
medication adm., oxygen, learning how to word this section
dressing changes, turning, either as stated or as
S & S from Dx that your Decreased Mobility (of any kind) when they do not even look at the
enema, catheter insertion, revised or Discontinue Plan.
pt is having right now Risk for Infection** planning section. Write this down.
If no S&S right now, just Risk herapeutic Regimen*
T
of Ineffective Management of nutrition, fluids, etc. NOTE: You must have
list the Dx as support Teaching of patient & family Document: Date/Time something to back up this
*T hese problems must have specific
(includes not only what the 1. Observations you made evaluation in your
2. Medication List data, measurements, lab tests, etc. in doctor orders but what you as 2. Reporting observations and documentation in the
Side effects? order to use these problems. the “nurse” will teach the changes in condition to Implementation column
patient. Also should include appropriate personnel (Implementation supports or
**T here may be some very specific proves your evaluation
3. Abnormal Lab? cases where it may be applicable.
how you will determine the 3. Care given to the patient
patient’s understanding of the statement).
T hink, what can an “infection” can 4. Response of the pt to the care
cause? Use that as a problem instead. teaching.) 5. Results of your actions, Examaple:
diagnostic tests, medications Goal was partially met. The
Goal: What do you plan to Be very SPECIFIC and very administered, etc. patient washed his face but did not
accomplish? Must be pt - THOROUGH. Include details like 6. Teaching specific to patient brush his teeth himself. The
centered, AND specific, how much, frequency (how often), problem still exists. Continue
meds, needs, problems, with the plan as revised.
measurable, attainable, etc. preventative care.
realistic, & time-sequenced. DATE REVISIONS OR
ADDITIONS EVERY DAY! DATE ENTRY EVERY DAY!

32.  Mr. Goodpatient is a 60 year old male admitted
with a diagnosis of acute myocardial infarction.
This is the data collected during the assessment.
Subjective: Mr. G. is complaining of severe
crushing chest pain unrelieved by rest which
has lasted for 2 hours. The pain is substernal
and does not radiate. He states the pain is a 9
on 0-10 pain scale. He says he smokes 2 packs
of cigarettes per day, is a manager at an
electronics firm, and that his father died @age
59 of a heart attack

33.  Objective Data:
 Vital signs: Pulse 110 and irregular
 BP 90/68
 Resp. 28
 His cardiac monitor shows sinus tachycardia
with frequent PVCs
 His heart sounds are normal except for the
irregularity and his lungs are clear.
 He is pale, diaphoretic, and holding his chest.

35. http://www.youtube.com/watch?v=fU0f5
bgbj0s&feature=related

36.  http://www.youtube.com/watch?v=gBzJGck
MYO4

37.  DeWitt, S. (9th ed), Medical- Surgical Nursing
Concepts and Practice, St. Louis, Mo., Saunders
PowerPoint's.
http://emievil.hubpages.com/hub/7-Bad-Study-
Habits-A-College-Student-Must-Not-Have
Microsoft clip art and microsoft office
Case studies from previous classes and patient
files.