But allow me to present an alternate reality to you. There is an evolution that occurs in new grad nurses (I’ve seen it over and over again). They come out of school bright-eyed and excited to care for “real” patients. They are “so glad” that they never have to do another care plan . . . This (stuff) get’s real. They discover how hard being a nurse is . . .
After about 6 months they begin to get the hang of things . . . by a year . . . they’re really getting their own legs as a nurse. They walk into a room and can assess the situation fully. They can determine how a shift will go within a couple of minutes. They have a sixth sense about them . . . a nurses sense.
Care Plan Database
We’ve created an enormous database of care plans for you to reference in nursing school. Check them out below.
The new nurse has developed “critical thinking” without even knowing it. They are working through nursing care plans while considering a million different variables right on the spot . . . without even realizing it!
Those pesky little care plans are being developed, adjusted, evaluated . . . patient after patient, shift after shift.
And the nurse doesn’t even realize it.
So they continue to talk about how pointless care plans are and tell students: “You’ll never do those in REAL life.” . . . little do they know, they’ve worked through multiple care plans during that shift.
I mean . . . think about it.
I arrive for a shift and hear about a patient who has some blanchable redness on the coccyx. BOOM!!!
The care plan is done . . . “risk for impaired skin integrity” . . .never technically entered my mind, but I’m already planning out the shift . . . how will I keep the skin dry, how often will I turn the patient, are they eating enough, do I need to get some barrier cream for them . . . see what I’m saying?
5 Steps to Writing a Nursing Care Plan
At NURSING.com, we want you to find a bit of excitement and comfort when writing care plans . . . little tip: they aren’t going away! So, here are the 5 steps:
Think About How
Step 1 – Collect Information
Get information from all sources together
Your head-to-toe assessment
Conversations with patients and loved ones
Observations (lab values, vital signs)
Report (or your report sheet)
Chart review and notes
Discussions with health care team members
Step 2 – Analyze
Look at all information
What are areas in which this patient has trouble and therefore needs to progress in?
Think about the ways you could see the patient improving and how you would know they were improving
Write down the general issues, how you’d help them progress in that area, and how’d you’d know they were progressing
(Tip – don’t worry about writing it in perfect NANDA-I, NIC or NOC terminology… just write it down in as you think of it)
Step 3 – Think About How
Think about how you knew these were issues
How did you know he was in pain? Did he tell you? Did you observe it? Was he getting pain medications?
Look at each “how” and decide if it is subjective (is this pain or something the patient told you about?) or objective (did you gather this info with your 5 senses?)
Write an S or an O next to them
What could these issues be related to?
A recent surgery, trauma, or disease process?
Write all of your reasons (again in layman's terms) under the problem(s) you’ve identified
What would you do to make this better? (Interventions)
How would you know it got better? (Evaluation)
Step 4 – Translate
Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
Look up the official terms for the problem(s) and write them down
Look up outcomes and interventions that may align with what you wrote down
Step 5 – Transcribe
Get your nursing care plan template out
Put the pieces together (problem + related to factor(s) + defining characteristics/”hows”)
Create your nursing diagnosis
Use your S’s and O’s to place your subjective and objective data
Write out your interventions and outcomes/evaluation
Sometimes all you need are a few examples to help you learn how to do a difficult task and to get the brain juices flowing. Here are 5 care plans that I personally wrote during nursing school.
MEDICAL DIAGNOSIS: Pneumonia
RATIONALE for INTERVENTIONS
Ineffective tissue perfusion(renal) RT cardiac abnormalities (a fib, HF), Diabetes Mellitus AEB decreased hemoglobin and hematocrit, elevated BUN and creatinine
The client will demonstrate improved tissue perfusion evidenced by improved lab values.
The client will show long-term improvements in lab values and energy levels, pt will verbalize improved abilities to
RN will assess causative factors and any contributing factors.
RN will encourage pt to change positions every 1-2 hours.
RN will instruct pt regarding ROM exercises and assist the pt with ROM exercises and walking.
RN will instruct pt on factors to improve blood flow and decrease the risk of the importance of continued smoking cessation.
Understanding the causes of renal failure, and heart failure will aid the patient in making life changes to avoid further tissue damage.
Changing positions regularly will not only prevent ulcer formation but also aid in improved peripheral blood flow.
ROM and walking will aid in peripheral blood flow and decrease the stasis of blood.
Smoking causes vasoconstriction which will contribute to further heart and renal problems, quitting will slow the process and improve vascular flow.
I feel that in many ways the patient understands the teaching, but I also think that he is older and does not have much of a desire to change and would rather simply live each day despite the consequences. I am very curious about his long-term health.
Pt states that he is tired, and unable to eat, his wife states that pt appears more weak than normal, the client reports excessive stress due to the disease process, pt states long-term hx of smoking (20 pack years)
Hemoglobin 8.9, hematocrit 28, BUN 35, GFR 23, history of heart failure, EKG demonstrating 1-degree heart block, slight bradycardia, diminished capillary refill
MEDICAL DIAGNOSIS: Aspiration Pneumonia
RATIONALE for INTERVENTIONS
Risk for aspiration RT depressed coughing/gag reflex AEB productive cough, current case of pneumonia (aspiration), immobility, hx of bowel obstruction
The pt will not experience aspiration during the shift as indicated by nurse implementing measures to prevent aspiration and pt naming foods and fluids that are high risk for aspiration.
RN will insure that the head of the bed remains elevated.
RN will assess position and condition of Gtube during regular vital assessments.
RN will instruct pt on foods and fluids that can lead to aspiration.
RN will closely monitor patient during feedings to watch for signs of aspiration.
This will aid in preventing the aspiration of fluids and foods into the lungs.
Assessing the position of the tube will insure that the tube remains patent and is not pulled farther into the stomach of that it is exiting the stomach.
Certain foods can increase the risk for aspiration (thin liquids, foods that crumble).
Ensuring that the patient is only eating safe foods, chewing correctly and swallowing food completely, and not drinking thin liquids will aid in monitoring for aspiration and insuring that pt is not aspirating.
Reference: Medical-Surgical Nursing: Critical Thinking in Client Care 4th Edition.
Pt did remain free of aspiration during shift. He would benefit from further evaluation and education regarding aspiration and possible risk factors. He has a home care nurse that generally assess his condition, but further education on how to prevent aspiration could improve health.
Hx of aspiration and swallowing issues, client reports he has SOB, hx of respiratory failure, HF
wet breath sounds, O2 sat 86, BUN 70 indicating dehydration, creatinine 2.12, T 98.9, 133/74, P 106, coughing after drinking and eating
MEDICAL DIAGNOSIS: Amputation
RATIONALE for INTERVENTIONS
Risk for infection RT DM, recent surgery AEB elevated WBC count, wounds with eschar, elevated blood sugars, neuropathy
PT will verbalize signs and risk factors of infection and ways to prevent infection.
Pt will remain free of infection during the hospital stay.
RN will instruct the pt on the signs of infection including temp, swelling, and redness.
RN will assess wounds for signs of infection during regular vital assessments.
RN will instruct pt on factors that increase the risk for infection including smoking, DM, and malnourishment.
RN will utilize aseptic technique when changing dressings.
When the pt knows the signs of infection they will be able to monitor for infection when at home and report signs prior to severe infection.
Monitoring for infection will insure that the client is receiving proper care and that infections are controlled.
The patient experiences several risk factors that potentiate his risk for infection by educating him on these risk factors he can begin to control the risks.
Preventing nosocomial infections is an important part of nursing. Insuring that at risk pts do not receive preventable infections is vital to proper care.
Source: Nursing Diagnosis: Application to Clinical Practice Lynda Juall Carpenito
PT is experiencing severe depression over his medical condition and is not able to think very far ahead and consider the implications of his current choices. He would greatly benefit from education and home health.
Pt appears depressed and somber, pt appears drowsy, pt complains of constipation
Pt states “I can’t do this anymore”, WBC 33, A1C 16, recent amputation of rt hand, open wounds with eschar on rt buttocks and rt heal, loss of hair on legs, temp 101
PT will verbalize importance of ambulation and fluid intake and deep breathing as a means of loosening secretions.
PT will demonstrate a productive cough and will begin to clear lung fields as evidenced by CXR and lung fields being clear to auscultation.
RN will instruct the pt on the proper method of deep breathing and encourage the patient to practice deep breathing.
RN will assist the patient to ambulate twice during shift.
RN will monitor breathing and O2 sats to insure proper oxygenation.
RN will allow and instruct on importance of rest periods prior to eating and ADLs.
RN will encourage coughing and fluid intake.
Deep breathing will aid in clearing lung fields and providing the body with adequate ventilation.
Ambulation will aid in loosening secretions.
Closely monitoring breathing and O2 sats will aid the nurse in monitoring for acute changes in respiratory status.
Rest periods prior to eating will aid the patient in restoring oxygenation and decrease orthopnea.
Continuous coughing and fluid intake will aid in loosening secretions and aid in improving ventilation.
PT demonstrated an improved understanding of the importance of fluid intake and deep breathing and ambulation. PT resisted ambulating but her daughter was able to aid in getting the pt out of bed and moving.
Pt reports SOB, pt denies pain, pt states she is tired and weak
Crackles in lung fields, orthopnea, continuous cough with no expectorant, RR 18, P71, Temp 98.9, pCO2 33
MEDICAL DIAGNOSIS: Appendicitis
RATIONALE for INTERVENTIONS
Stress Overload RT work and family responsibilities (multiple co-existing stressors) AEB pt statements “I am supposed to be in Chile on Monday”, work load over 50 hrs/week, reported travel
Patient will review the amounts and types of stressors in daily living and identify two interventions that can be completed in daily life to reduce stress by 12pm.
RN will listen actively to pt as he describes life stresses.
RN will instruct the pt on stress reduction activities (deep breathing, guided imagery, yoga).
RN will assess stress level with vital signs assessment.
Encourage pt to discuss stresses with spouse and children.
Actively listening to pt will aid them in feeling like they are able to discuss their stress openly. Openly discussing stress can help in reduction.
Stress reduction techniques can aid in coping with life stress and aid the pt in improving coping skills.
Continually monitoring stress levels can aid the pt and nursing staff in identifying possible root causes of stress and better implement interventions.
Discussing stress with loved ones can help the patient and family understand the feelings and emotions the pt is experiencing and aid him in knowing that he can turn to when stressed.
References: Varcarolis, E., Halter, M. (2010). Foundations of psychiatric mental health nursing: A clinical approach 6th. Saunders, St Louis.
Pt was able to identify stress in his life and admitted that current symptoms may have been exacerbated by stress in his life. He stated that he will begin to journal his thoughts and feelings and stated this helped him in identifying stress in his life.
Pt states” I am stuck in here and I am supposed to be in Chile on Monday”, pt reported abdominal pain, pt states he feels nauseous
This will not only serve you well in nursing school but also in your career as a nurse. We can all fall into the ruts of assuming things prior to taking in all the available information even as practicing nurses.
If you apply these 4 steps to master critical thinking without prior judgment it will make you a better nurse and keep your patients safe.