Care Plans 101

A guide to nursing school care plans

Care Plans. You’ve heard about them. You might be scared of them. You may have no idea what’s going on. You’re not alone. This guide will introduce and explain different parts of a nursing care plan.

**My advice for going through this guide is that you try not to digest this entire article in one sitting. Take it section by section, or maybe follow along with your class schedule. Always follow your school/instructor’s guidelines and keep in mind that I’m writing this from my perspective and my experiences.**

The Nursing Process (ADOPIE)

The Nursing Process can seem very daunting. Nursing school instructors will talk about the nursing process every single day. A good foundation will allow you to use the nursing process in your favor, rather than it being something that causes you to slow down. Think of the Nursing Process as a form of the Scientific Method that you learned in elementary, middle, high school, and your prereqs.

Here I will take you through a patient scenario.

A.B is a 35 year old Chinese female who comes to the emergency room for “the worst pain ever” in her lower right abdomen. She reports that the pain started last night a few hours after eating dinner. She tried ibuprofen and tylenol last night with little to no relief. The pain is radiating from her belly button to her right lower quadrant. She is also reporting some nausea but no vomiting. The patient reports 8/10 pain.

Assessment

Nursing assessment is so important that it requires an entire class in the nursing program. That “RN” behind your name when you graduate nursing school and pass the NCLEX allows you to assess your patients and decide on nursing interventions based on this assessment.

During your assessment, you will have subjective information and objective information. My nursing program spent several days going over these definitions, and I could probably write an entire page on just this information.

Put simply:

Subjective: What the patient says.

Objective: What you (the nurse) observes.

You want to start your narrative with basic patient demographics and a quick statement about what brought them into the doctor/hospital. Use direct quotes from your patient–this is your subjective information.

A.B. is a 35 year old Chinese woman who presents to the ED reporting “the worst pain ever” in her lower right abdomen.

Everyone writes their assessment differently. You want to provide quick and concise information. What did the patient say? What did you observe? A head to toe assessment may not necessarily be appropriate if you are in the emergency room, but if you are in a Med-Surg or ICU, be as detailed as possible! Nursing school will most likely require you to write down everything you assessed.

Add in your vital signs, a quick mental status exam, and then begin writing OBJECTIVE information. Never write assumptions or opinions in your nursing notes. This will leave you open to a lot of legal liability.

A.B. is a 35 year old Chinese woman who presents to the ED reporting “the worst pain ever” (*8/10*) in her lower right abdomen. Vital signs 130/92 BP, 100.4 temp oral, HR 98, RR 22. Neuro: Alert and oriented x 4, body movements are voluntary and deliberate, facial expression is appropriate to situation, word choice is effortless and appropriate to age and educational level.
Head, face, and neck: Head is normocephalic, face and eyes are symmetrical. Nose is symmetrical with no deviations. mucous membranes of the mouth are moist, teeth are white and intact. No redness or swelling in the throat. PERRLA.
Respiratory: Thorax is symmetrical and symmetrical chest expansion is noted bilaterally. AP diameter is less than transverse diameter. No retractions or use of accessory muscles. Breath sounds are clear, regular, and unlabored bilaterally. No wheezing, rhonchi, or stridor noted.
Cardiovascular: Apical heart rate is regular, S1/S2 noted. No murmurs present. All pulses are equal and 2+ bilaterally. Cap refill is less than 2 seconds.
Gastrointestinal: Abdomen is flat, symmetrical, skin color is even, umbilicus is midline. Bowel sounds present in all 4 quadrants. Tenderness upon palpation in the right lower quadrant. No masses noted. Last bowel movement reported yesterday evening.
Genitourinary: Pt reports voiding at regular intervals. For privacy of patient, inspection was not done of the genitals upon initial assessment, will wait for MD.
Musculoskeletal: Gait is smooth, stable, and even. Muscle strength is equal bilaterally with upper and lower extremities.
Skin: Color WNL, warm temperature, smooth texture, good skin turgor. No rashes. Right AC peripheral IV is infusing well with no redness.

Don’t be overwhelmed!! In school, you will go through each body system one by one and get used to writing your observations. My little sample above is either really simple or really detailed depending on how you look at it. When I take or give report, there are a lot of acronyms thrown around that will shorten your note taking. You will also find your own ways to write that will become easier and easier.

You may also find yourself using acronyms like WNL – within normal limits. Writing that a body system is WNL means that there is NOTHING abnormal about that body system.

Tip: do not write any assessment data that you yourself did not observe.

Diagnosis

What the heckles is a “Nursing Diagnosis” and why do I need to learn it? Who is NANDA?

Alright. This part was the strangest for me to learn.

As nurses, we cannot medically diagnose anyone. We take the MD’s diagnosis and adjust our care accordingly. Nursing diagnoses allow us to apply certain nursing interventions along with doctor’s orders.

For example, the patient in the example above is experiencing acute pain. Pain itself is not a medical diagnosis. Right now we don’t know why A.B is experiencing pain, so let’s say that the doctor ordered a CT scan and it shows an inflamed appendix.

Throughout nursing school, I have been using Ackley and Ladwig’s Nursing Diagnosis Handbook. This book has every NANDA nursing diagnosis, interventions, and rationales. It even breaks things down by patient population. It has been the perfect companion for all of my care plans, and it is one of the only books I chose to purchase rather than rent.

In any patient scenario for your care plans, you may be asked to choose any number of nursing diagnoses. Some of my care plans only had one, and others had up to ten. My advice is to choose them based on priority. That means you need to check off your ABC’s, vital signs, and pain first. This essentially covers the base of the pyramid on Maslow’s hierarchy of needs.

For example, if the patient is having crackles/rhonchi upon auscultation and an O2 sat of 92%, then you need to choose something related to airway/breathing, even if they are coming in with a chief complaint of a broken arm. It sounds strange, but you always always need to remember your ABC’s!

Let’s break down what a full nursing diagnosis looks like! It has three components. It is easier to just take one part at a time. We have already gone through the basis for choosing the “Nursing Diagnosis” component. In the United States, we use an approved NANDA (North American Nursing Diagnosis Association) list to choose the first component.

Let’s follow this diagram to create a nursing diagnosis statement for our patient A.B.

Nursing diagnosis: Acute Pain
Wait a second, Skyanne. Didn’t you just tell me to prioritize vital signs above pain? What is going on here?

Let’s review the vital signs. 130/92 BP, 100.4 F temp oral, HR 98, RR 22. They are all slightly elevated. This is where you need to make a judgement call. Go over which is more life-threatening. This patient could probably use some Tylenol, but a 35 year old otherwise healthy woman can probably handle a small fever for now. You want to keep an eye on it, but it isn’t a priority. All other vitals signs are elevated for a specific reason, and that is because she is in acute pain. If we treat the pain, her vital signs are probably going to improve.

If we had a pressure of 80/40 and a fever of 104.2 F, we would probably alter our priorities. Now, let’s go over what is physiologically causing the pain and put it in our nursing diagnosis statement.

Remember that the MD ordered a CT scan which showed an inflamed appendix. Since we cannot “diagnose” appendicitis, we need to treat based on the pathophysiology. It’s inflammation! It could be an infection, but let’s say we are still waiting on a lactic acid and CBC.

Nursing diagnosis: Acute pain related to tissue inflammation

Yes, it’s that simple! Ackley and Ladwig’s Nursing Diagnosis Handbook actually lists out some examples of what your “related to (r/t)” could be for each nursing diagnosis. That way you don’t have to come up with something out of thin air. Your instructors or classmates can also be a good resource if you get stuck.

Another example might be if you having a scenario with ineffective breathing, your “related to” may be neuromuscular dysfunction or anxiety.

Now there’s only one part left! If your first two components are strong, this is the easiest part. All you are doing is finding evidence that supports what you have already said. What makes you say the patient has acute pain? What have we observed that supports this claim?

Nursing diagnosis: Acute pain r/t tissue inflammation as evidenced by abdominal tenderness upon palpation, elevated heart rate, and a patient report of 8/10 pain.

You do not need to list three pieces of evidence. We usually choose one for our statement, but I wanted to show you that you can pull either simple or complicated evidence.

You made it this far! Is everything coming together? Remember to take this guide bit by bit. If you are still feeling confused, this is a great place to stop and read again before continuing to the next part.

Outcome Identification (Goals)

Ready to continue? Great!

Have you ever heard of the acronym S.M.A.R.T? I actually heard of it from one of my old bosses. He used it to help us meet our sales goals. But I also learned more about it my first semester of nursing school!

This is a great acronym you can use to plan goals for your patient. Take a look at each component. It is easy to think that you are going to heal your patient completely during the shift or that you want the patient to be pain-free But you need to look at everything as a whole clinical picture. In a real clinical setting, you can discuss this section with your patients. Ask them what they would realistically like to accomplish.

Our campus divides goals into short-term and long-term. Short-term is typically up to one shift, maybe two. Long-term can be anywhere from two days-several months. We also have specific language we use to distinguish goals from planning. A patient goal should start with “Patient will…”

A short-term goal for our patient could be

Patient will verbalize a pain of 5/10 or lower before she goes to surgery.

This is a very simple goal. Your goals do not have to be complex. Let’s walk through each component of “SMART.”

  • Specific – This goal is specific to our patient, and it narrows down to the patient’s pain rating.
  • Measurable – Notice here that I did not say, “Patient will report less pain…” We can use the numeric pain scale to measure how well the patient is responding to our interventions. If the patient says, “I’m feeling better,” that could mean anything. Here we are turning a subjective feeling into an objective measurement.
  • Attainable – The patient reports an 8/10 pain for her inflamed appendix. If you’ve ever had appendicitis, you know that it feels like your insides are being ripped out. I’ve personally had appendicitis, and it was excruciating. Our goal of 5/10 or less is considering that the pain will not go away until surgery is done.
  • Realistic – This ties into also being attainable. If we set a goal of 2/10 or less, that would be unrealistic. When I had appendicitis, it took a lottttt of morphine to even get me down to a 4-5.
  • Timely – This is as simple as adding “by the end of my shift,” or “until the patient goes to surgery.” You need some sort of time limit on your goal.

I hope this is making sense. Setting goals can take some practice. Utilize your resources to come up with goals! You can ask your classmates, instructors, preceptors, and even your patients!

Planning/Intervention

This is the part of a care plan where you come up with everything you can do within your license to help your patient. I highly recommend using a nursing care plan book, or diagnosis handbook. Get the one I use by clicking here! My Med-Surg textbook also has sections with the nursing process in it. I got a lot of my interventions from this book as well.

This part became super easy to me once I got comfortable in clinicals. On paper, a list of 20 nursing interventions seems excessive. If you have already been to clinical, you know that nurses can assess dozens of things without even thinking twice.

Let’s talk about how to come up with interventions. Hopefully I can explain this to you in an easy way!

I ask myself a series of questions when I am coming up with interventions for my patient:

  1. Which interventions am I doing for my patient already?
  2. What types of things would I do at home if I were having this issue with myself or a family member?
  3. How can I include the patient in their care?

So using these questions, let’s talk about pain.

  1. I am already monitoring my patient’s vital signs. Maybe I’ve already given pain medication ordered by the doctor. I have also assessed my patient’s abdomen and pain rating. That’s four separate interventions right there!
  2. If a family member were having abdominal pain, maybe I would turn the lights down and create a quiet environment. Maybe an ice pack would help. Maybe that person would like to be distracted with a family member, music, or a TV show!
  3. For acute pain, it can be hard to include the patient because that patient is most likely scared or anxious. You could teach the patient how to perform relaxation techniques.

Don’t be afraid to write out more than what you think is necessary, and then narrow it down from there. I go back and edit my interventions all the time.

Don’t forget to cite your sources!

Evaluation

You’ve made it to the end of your care plan! Hopefully…If your program is anything like mine, it seems like there’s always some extra work to do.

My first semester of nursing school, evaluation got swept under the rug (in my head). I did not take it seriously because I was never able to follow up with a patient the next day, or I was so caught up in trying to just keep up with my preceptor.

Go through each goal you set. The bottom line is, did you meet the goal or did you not meet the goal?

If you did not meet the goal, that’s okay. You did not fail your patient. You are not a bad nurse. Take the time to evaluate your goals and your interventions.

There may have also been unknown and uncontrollable things that happen on your shift. Scratch that. There WILL be unknown and uncontrollable things that happen on your shift.

Make sure to debrief with your instructor or preceptor if you are continually not meeting goals. They are there to help you!

Conclusion

If you are still reading this, I am a happy woman. Thank you so much for getting through this guide. I hope it was helpful and I hope it felt more like a conversation than a lecture.

This is not meant to be an all-inclusive guide. Writing care plans takes a lot of practice and patience.

If you have any questions or comments please let me know!


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