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How to Write a Good Care Plan for Nursing School
Arghhh! The Dreaded Care Plan!
Most nursing school students get halfway into their first semester and realize how much fun it is to write care plans for their patients...NOT! Care Plans seem to be a time-consuming, purposeless endeavor that teachers give their students to keep them stressed out. However, these Care Plans can have a purpose and can ultimately help you learn the best way to plan care for your assigned patients and for future patients when you are an actual nurse.
In this article, I would like to provide you with advice as to how to write an effective and well-put-together Care Plan that will leave your teacher saying, "Good Job." Care Plans seem tedious and ridiculous at first, but once you realize what your teachers are looking for you will become much more efficient at writing them.
1. Find Out Your Teacher's Expectations
The first thing that you'll need to do in order to write a decent care plan is to find out what your teacher's expectations are. It seems to many of us that our teachers would just tell us what they're expecting of our Care Plans, but the problem is that many times they do not tell us and we end up guessing. We throw together a 20 page Care Plan that has a lot of information and a lot of time put into it, but the Care Plan itself does not flow, does not apply to the patient, or is not realistic. And then what? Our teachers hand the Care Plans back to us and tell us to re-do it or fix all of the items in red.
So save yourself some time this weekend and ask your teacher today what her expectations are for your care plans! Easy as that. Ask him/her how long it has to be, what they are looking for in terms of content, do they want to see all of the patient's labs, assessments, diagnostics, meds, etc. or just the ones that pertain to the main diagnosis. And other questions like these.
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2. Gather Appropriate Information
Once you know what your teacher is expecting of you, you'll know exactly what information you'll need to collect while in the clinical setting. If your teacher says you'll only need information pertaining to your client's two main diagnoses, then that means you don't have to write down every single detail of the client's history or any labs, meds, etc. that might not pertain to their condition at hand.
Tip: NEVER include patient identifiers on your information paper (this means don't write the person's name, DOB, address, etc). This would be a HIPPA violation (it breaks confidentiality). And it could get you kicked out of school!
So gather the appropriate data to put together a relevant care plan. Don't waste your time at clinicals writing down patient information all day long when you could be getting in some good clinical experience!
3. Identify Your NANDAs
Your first semester of nursing school you might find it difficult to come up with the dreaded NANDAs for your client, but as time goes on you will find it difficult to narrow it down to just one! You'll find that pretty much every client has a minimum of two NANDAs that could be applied to the care plan if not a dozen or so more than that.
My suggestion is to find the priority NANDA(s) and go from there. If your patient is in the hospital because of CHF, obviously you'll want to choose a NANDA(s) related to that condition (for example: Decreased Cardiac Output, Fluid Volume Excess, Etc.) Go off of the patient's main diagnoses and choose a priority NANDA in direct relation. Or if you need a different way of thinking up a NANDA, think of your ABCs (airway-breathing-circulation). For example, if the person is in the hospital with pneumonia, you'll want to choose a NANDA like Ineffective Airway Clearance or Impaired Gas Exchange. Of course don't choose a NANDA that doesn't actually apply to your patient.
Also, you should be thinking of exactly what you did for this patient while in clinicals. If you choose a NANDA for which you contributed nothing during your time with this patient, you're going to have a difficult time coming up with a legitimate care plan for that patient, right? This point ties into my next tip.
Comfort & Safety
Ineffective Airway Clearance
Impaired Skin Integrity
Impaired Gas Exchange
Risk for Infection
Decreased Cardiac Output
4. Use Real-life Interventions
I think the biggest problem I had with putting together care plans was that I wasn't thinking of what I actually did for my patients. Instead I was looking up "suggested" interventions in a Care Plan book and putting that into my care plan. You can see how this would look un-realistic to my teachers that wanted to see real-life data.
So my tip is to spend all of your clinical time with your assigned patients, and do whatever you can (within your scope) for them. Then look back at your day and write down everything you did for your patients, then tie these interventions into your care plans for them. They would obviously be realistic interventions, because you did them in real life, right?
Some interventions that are obvious but that you might overlook while writing your care plan include:
- Checking Vital Signs q 8 hours (this could go along with SO many NANDAs!)
- Monitoring Respiratory Rate, Depth, Pattern (obviously falls into place with every respiratory NANDA and probably Cardiovascular, as well)
- Providing oral fluids (when appropriate for dehydrated patients - Fluid Volume Deficit or Decreased Cardiac Output as NANDA)
- Applying 2L Oxygen via Nasal Cannula (for many respiratory NANDAs and Cardiovascular NANDAs)
- Cleaning up patient's room to de-clutter and prevent falls (Fall Risk as NANDA)
- Assisting with AM care - bed bath, mouth care, etc. (Risk for Infection as NANDA)
And the list could go on. Again, just think back to what you actually did to help your patient and add that to your care plan's interventions. After I started applying real data to my care plans, it got easier and easier to write them, and my teachers were happy! And I saw less red marks on my care plans, if any at all.
Having a Care Plan Book Can Be Helpful...But Don't Pull All Your Data From a Book!
5. Also Use Realistic Outcomes
Just as you will be using real life data for your interventions, you want to also use realistic outcomes. This means that your outcome or goal for that patient should be something that is actually achievable for that patient. For example, if your patient had a major car accident and his legs were crushed on impact, you're not going to make your outcome for this patient "patient will walk again with no pain by discharge." Do you think that would be realistic to expect an elderly patient to be walking again with no pain after his legs have been crushed? Probably not.
A more realistic outcome for an elderly patient with fractured femurs would be "patient will actively participate in range of motion activities by end of shift."
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© 2014 Nicole Canfield