nursing care plan template

Posted: October 29th, 2023

Nursing Care Plan Template

A comprehensive nursing care plan template, a document that details the intervention strategies and care objectives for a patient, will effectively guide you into writing an informative care plan. On the other hand, you can define a care plan as a written document that contains the diagnosis and treatment plan of a patient. It is created by a nurse and is founded on an in-depth analysis of the patient’s needs, which include psychological, physical, social, and spiritual demands. In addition, the nursing care plan serves as a roadmap for nurses’ interventions and guarantees that patients receive thorough, specialized care.

Nursing Care Plan 

Your nursing care plan should consist of certain features. In fact, these will determine whether your care plan is valid or not. Importantly, these components include:

  • Assessment: The patient’s health status, medical background, current medications, allergens, and other pertinent information are described here.
  • Diagnoses made by nurses based on the patient’s health issues are listed in this section.
  • Objectives and results: This area of study discusses the nursing interventions’ anticipated results as well as the timeline for reaching them.
  • Interventions: The nursing interventions that will be used to produce the intended results are included in this section. They could consist of drugs, therapies, operations, and other treatment strategies.
  • Evaluation: This part of the report details how the patient reacted to the nursing actions and any alterations to their health.

A care plan should be modified on a frequent basis to account for changes in the patient’s health and reaction to care. Most importantly, teamwork between nurses, patients, and other healthcare providers is necessary to create effective nursing care plans that guarantee the patient receives thorough and integrated care.

Nursing Care Plan Writing Help

One of the things that is mandatory for all nursing students to learn how to write is a nursing care plan. However, this can seem like an uphill task especially for nursing students who have other things to juggle. When it comes to this, it is advisable to seek the professional help of nursing care plan writers. nursesessay.com offers one of the best and trusted nursing care plan writing services. Our highly skilled writers have been in nursing school and totally understand the requirements of this documents. Feel free to reach out to us any day, any time. Nevertheless, we have the most affordable prices.

Nursing Care Plan Examples

Keep in mind the definition of a nursing care plan before tackling any section, it is an official document which states the nursing care meant to be given to a patient. Along with a list of the patient’s medical issues, it also contains the nursing diagnosis, goals, interventions, and evaluations. You will need to prepare this document for all inpatients regardless of their illness. Below are nursing care plans examples.

Nursing Care Plan for Impaired Mobility

Nursing Diagnosis: Stroke-related limited range of motion, diminished balance, and mobility issues caused by muscle weakness.

Goals:

  1. The patient needs to regain strength and movement within four weeks.
  2. Patient needs to increase the level of movement within two weeks.
  3. He/she needs to be able to walk without help after six weeks.

Interventions:

Three times a day, encourage the patient to do range-of-motion exercises.

Evaluation:

The patient has gained back mobility as well as strength as demonstrated by improved flexibility and motion and enhanced potential to ambulate independently.

They can walk without aid, neither with the walker nor with a cane.

Patient is able to do daily tasks independently.

Plan of Nursing Care for Breathing Pattern that Is Not Effective:

Breathing pattern dysfunction associated with respiratory distress is the nursing diagnosis.

Goals:

The patient will keep his or her breathing rate constant at 12 to 20 breaths per minute.

Patient might very well maintain oxygen saturation levels above 90%.

They will demonstrate how to deep breathe and cough effectively.

Interventions:

Every four hours, check on the patient’s breathing.

Give oxygen as indicated.

Every two hours, remind the patient to take a deep breath and cough.

Raise the head of the bed to encourage proper lung expansion.

Track the symptoms of respiratory distress.

Evaluation:

The patient keeps his or her breathing rate constant at 12 to 20 breaths per minute.

Patients’ oxygen saturation values remain above 90%.

They patient shows efficient coughing and deep breath control.  

 

Nursing Care Plan for Risk for Infection

Nursing Diagnosis: Risk for infection pertaining to an open wound.

Goals:

The patient would then maintain intact skin.

Patient should be free from signs as well as symptoms of infection.

They should be informed on proper wound care.

Interventions:

Every shift, check the wound for indications of infection.

Apply antibiotics as directed.

Dry out the wound and keep it clean.

Keep an eye on the patient’s white blood cell count and temperature.

Inform the patient’s family about how to properly treat wounds.

Evaluation:

Skin on the sufferer is still intact.

The patient is free of infection-related symptoms and signs.

The patient and family are capable of performing appropriate wound care.

 

Nursing Care Plan Template

It acts as a manual for nurses to make sure they give their patients the finest treatment possible. Nonetheless, below is a sample nursing care plan that can be altered to meet the needs of each patient:

Patient details:

Name:

Age:

Sex: 

Sex: 

Medical History:

Allergy:

Diagnosis:

Based on the patient’s medical state, symptoms, and assessment results, determine the nursing diagnosis.

Objectives and Results:

State the patient’s preferred objectives and results based on the diagnosis.

Healthcare interventions

Identify the care plan that will be used to accomplish the objectives and results. They may consist of:

Medications

Viewing vital signs

Evaluation and recording of symptoms

Education of patients

Taking care of wounds

Mobility and position

Hydration and nourishment

Evaluation:

Record any changes in the patient’s condition and assess the nursing treatments’ efficacy.

Lastly, it is significant to remember that nursing care plans should be tailored to each patient’s particular need. To give the greatest treatment possible, this template should be used as a starting point and adjusted as needed.

Nursing Care Plan for Hypertension

Typically, a care plan for hypertension includes the following actions:

Assessing a patient’s blood pressure, medical history, current medications, lifestyle choices, and any symptoms they may be feeling is the initial step in providing care for a patient with hypertension.

Although hypertension can be identified based on BP readings and a patient’s medical history, the doctor should be consulted by the nurse to confirm the diagnosis.

Planning: The nurse should create a plan of treatment that includes lifestyle changes, objectives for blood pressure control, and medication management based on the exam and diagnosis.

Implementation: The nurse should put the plan of care into action by instructing the patient on hypertension and how to control it, checking their blood pressure, encouraging healthy lifestyle changes like exercise and a balanced diet, and giving them prescribed medications.

Evaluation: The nurse needs to monitor the patient’s symptoms, blood pressure, and therapy response on a frequent basis. The evaluation may require a revision to the care plan.

An example nursing care plan for hypertension is provided here:

Assessment:

The patient’s blood pressure is routinely higher than 140/90 mmHg.

Patient reports weariness and sporadic headaches.

The patient has smoked in the past, and hypertension runs in the family.

The patient is currently receiving medicine for high cholesterol and diabetes.

Diagnosis:

Hypertension

Planning:

Goal: Lower blood pressure to under 140/90 millimeters of mercury.

Inform the patient on managing their hypertension, including the necessity of consistent medication use, lifestyle changes, and frequent blood pressure checks.

Urge the patient to stop smoking and start an exercise and healthy eating regimen.

Administer antihypertensive medicine as directed by your doctor arrange routine follow-up consultations to check your blood pressure and assess your treatment’s effectiveness

Implementation:

Inform the patient about managing their hypertension

Urge the patient to stop smoking and start an exercise and healthy eating regimen.

administer antihypertensive medicine as directed by the doctor keep an eye on the patient’s symptoms and blood pressure

Have routine follow-up sessions to check your blood pressure and assess your treatment’s effectiveness.

Evaluation:

The patient’s blood pressure is regularly less than 140/90 mmHg.

The patient claims to have more energy and have less headaches.

The patient has given up smoking and is now exercising and eating well.

Patient is taking medications as directed

The care plan is working and will be kept up with routine follow-up appointments.

Stroke Nursing Care Plan

The goals of nursing care plans for stroke patients are to limit complications, hasten healing, and ease rehabilitation. Here is an example nursing care schedule for a patient with a stroke:

Examine the patient’s neurological condition, taking into account their level of consciousness, their ability to move, and their sense of perception.

Keep an eye on your vital indicators, such as your heart rate, blood pressure, and respiration rate, and take action as necessary to keep them steady.

Implement the necessary interventions to prevent pressure ulcers by evaluating the patient’s skin integrity, especially in areas of reduced mobility.

Anticoagulants, antiplatelet, and thrombolytics should all be administered as directed while being watched for any potential side effects.

Provide the patient the proper diet and hydration, making sure they can swallow safely and keeping an eye out for dysphagia symptoms.

Take precautions to avoid aspiration, including raising the head side of the bed while feeding and keeping an eye out for choking or coughing symptoms.

Help with everyday tasks like washing, grooming, and using the restroom as needed; whenever possible, encourage independence and self-care.

Employ fall prevention strategies, such as creating a secure atmosphere and offering aid when required.

Work together with speech, occupational, and physical therapists to aid rehabilitation and encourage healing.

Inform the patient and their family about ways to avoid having a stroke, its warning signs and symptoms, and post-stroke management techniques.

Moreover, nursing care plans should always be customized to the needs and goals of each patient.

Anxiety Nursing Care Plan

Depending on the patient’s particular needs, nursing care plan templates for anxiety may differ, however the following is a typical outline that can be changed as necessary:

Assessment:

Use a standardized tool for anxiety evaluation to determine the patient’s level of anxiety.

Watch the patient’s behavior, as well as any physical symptoms of anxiety including perspiration, agitation, and an elevated heart rate.

Find out what stresses in the patient’s life or the environment cause them to become anxious.

Evaluate the patient’s coping skills and social support network.

Nursing Diagnoses:

Stress-related anxiety and situational anxiety.

Inadequate coping with stress and worry.

Self-harm risk associated with excessive concern and anxiety.

Planning:

Create a care strategy that takes the patient’s unique requirements into account, taking counseling, relaxation techniques, and medication management into account.

Urge the patient to engage in stress-relieving exercises or deep breathing techniques.

Explain to the patient how to properly manage their anxiety.

Help the patient locate their support networks and create coping strategies.

Interventions:

Promote the patient’s expression of their emotions and worries.

Administering medication in accordance with a doctor’s orders.

Provide a soothing and encouraging atmosphere for the patient.

Use therapeutic communication strategies to make the patient feel heard and understood, such as active listening and validation.

Teach the patient how to relax, including deep breathing and relaxing their muscles one at a time.

Engage the patient in activities that help them feel in charge and in control of their situation.

Evaluation:

  • Regularly reevaluate the patient’s anxiety level and coping skills.
  • Analyze the outcomes of the interventions and adjust as necessary.
  • Keep an eye on the patient’s reaction to the medicine and any side effects.
  • Check to see if the patient has learned new coping mechanisms and is successfully controlling their anxiety.

Acute Pain Nursing Care Plan

A thorough assessment of the patient’s level of pain is usually the first step in developing a nursing care plan for acute pain. This is followed by the creation of a personalized care strategy for controlling the pain. However, here is an illustration of a nursing care schedule for severe pain:

Assessment:

Using a pain scale, determine the patient’s level of pain (such as a 0-10 numerical rating scale).

Determine the source of the pain and its features (e.g., sharp, dull, burning, throbbing).

Analyze the patient’s reaction to earlier pain management techniques.

Examine the patient’s medical background and drug usage.

Nursing Diagnosis:

Acute Pain Caused by Underlying Condition

Planning:

Along with the patient, set reasonable pain management objectives.

Create a pain management strategy that is customized to the needs and preferences of the patient.

Inform the patient and their family members about effective pain management techniques.

Interventions:

When directed by the doctor, administer pain medicine.

Offer non-pharmacological pain management techniques like positioning, diversion, and relaxation methods.

Before and following pain management interventions, keep an eye on the patient’s vitals and level of pain.

Make sure the patient’s surroundings are suitable for pain management (e.g., comfortable, quiet, and low lighting).

Analyze and deal with any side effects of painkillers.

Inform the patient and their loved ones about the potential negative effects of painkillers and how to handle them.

Evaluation:

Regularly evaluate the patient’s degree of pain to see how well pain management measures are working.

Analyze the patient’s reaction to pain management techniques and make any necessary adjustments to the care plan.

Record in the patient’s medical file their level of pain and how they react to pain management techniques.

Nursing Care Plan for Sepsis

It is important that you know how to write a care plan for sepsis. Here’s a template to guide you.

Evaluate and keep an eye on the patient’s vital signs: Check the patient’s blood pressure, temperature, heart rate, and respiration rate every four hours or as directed by a doctor. Any substantial adjustments need to be notified right away.

Administer antibiotics: Follow the doctor’s instructions while administering prescription antibiotics. Make sure the patient completes the recommended antibiotic treatment.

Maintain fluid balance: Keep an eye on the patient’s electrolyte and fluid levels. Provide IV fluids as directed by the doctor.

As needed, use oxygen treatment to maintain proper oxygenation while providing respiratory assistance. Keep a tight eye on the patient’s breathing condition.

Watch the patient’s laboratory results, particularly the white blood cell count, lactate levels, and electrolyte levels.

Inform your doctor of any substantial changes.

Acute respiratory distress syndrome (ARDS), shock, hypotension, and disseminated intravascular coagulation are a few examples of consequences to keep an eye on (DIC). If any of these issues develop, notify the doctor right away.

Support the patient and their family emotionally: Support the patient and their family emotionally. Inform them of the problem and recommended course of action

Urge the sufferer to relax and refrain from exerting themselves. Also, make the patient’s environment peaceful and cozy.

The patient’s pain should be evaluated and managed. Apply analgesics as directed by the doctor.

Provide the patient nutritional support: Give the patient nutritional assistance, including enteral or parenteral nourishment if necessary.

Adopt and enforce infection control measures, such as maintaining good hand hygiene, using personal protective equipment appropriately, and taking any necessary isolation precautions.

A plan of care should be adjusted as necessary based on the results of the treatment effectiveness assessment.

Importantly, don’t forget to note each assessment, treatment, and evaluation in the patient’s medical file.

Nursing Care Plan for Asthma

Depending on the severity of the ailment, nursing care plan templates for asthma may differ, however the following is an example:

Assessment:

Determine the patient’s respiratory condition, including their pattern, rate, and depth of breathing.

The patient’s oxygen saturation levels should be watched.

Analyze whether you are wheezing, coughing, or experiencing chest discomfort.

Find out the patient’s complete asthma history, including asthma medication, triggers, and previous hospitalizations.

Determine the patient’s level of knowledge and comprehension on their asthma and self-management techniques.

Healthcare diagnosis:

Due to bronchoconstriction and increased mucus production, there is a reduction in gas exchange.

Due to increased mucus production, airway clearance is ineffective.

Fear of aggravation and anxiety associated with breathing difficulties.

 

Healthcare interventions

When directed, administer prescription bronchodilators such as albuterol.

Urge the patient to follow an action plan for managing flare ups and use a peak flow meter to assess their lung function.

Educate them on how to use an inhaler properly and how to manage their medications.

Tell the patient to stay away from triggers like cigarette smoke and allergies.

Urge the patient to drink more fluids to aid in liquifying mucus.

To encourage airway clearing, perform chest physiotherapy techniques such as percussion, postural drainage, and vibration.

Keep track of and record the patient’s reaction to interventions.

To keep levels of oxygen saturation stable, administer oxygen as necessary.

Encourage the patient to practice relaxation techniques while offering emotional support and reassurance.

 

Evaluation:

  • Analyze the patient’s respiratory condition, taking into account breathing depth, rate, and pattern.
  • Analyze how well interventions improve airway clearance and gas exchange.
  • Check to see if the patient is now less anxious and feels more capable of controlling their asthma.
  • Depending on how the patient reacts to interventions, the care plan may need to be modified.

Nursing Care Plan Anemia

Typical elements of nursing care plan templates for anemia include the following:

Further, assessing the patient’s medical history, symptoms, and the outcomes of the physical exam is the first stage in creating a care plan for anemia. This will assist in identifying the root cause of the anemia and how severe the illness is.

Oxygen therapy: To increase their oxygen saturation levels in patients with severe anemia, oxygen therapy may be necessary. As necessary, the nurse should change the oxygen flow rate based on the patient’s oxygen levels.

Iron supplementation: If iron deficiency is the source of the anemia, the patient may need to take iron supplements. The patient’s reaction to the supplements and any negative side effects should be closely watched by the nurse.

Blood transfusions: Patients with severe anemia could occasionally need a blood transfusion. The nurse should keep an eye out for any negative reactions while also monitoring the patient’s vitals and reaction to the transfusion.

Nursing patients with anemia should be informed about their disease, including the root cause, available treatments, and lifestyle changes that can help control the condition. This could entail making dietary adjustments to increase iron intake as well as advice on how to conserve energy and prevent fatigue.

Follow-up care is necessary for anemic patients who need constant observation. The patient’s healthcare provider should be seen on a regular basis, and nurses should keep track of how the patient is responding to treatment over time.

Lastly, nursing care for anemia aims to alleviate the patient’s symptoms and enhance their quality of life while simultaneously addressing the condition’s underlying cause.

Care Plan for Bipolar Disorder (Nursing)

The objectives of nursing care plans for bipolar disorder patients are to control their symptoms, avoid relapse, and enhance their general quality of life. A sample nursing care plan for bipolar disorder is shown below:

Assessment:

To spot any changes in the patient’s condition, evaluate their attitude, behavior, and way of thinking.

To safeguard the patient’s physical health, track their vital signs and test results.

Determine the patient’s functional ability and capacity for carrying out daily tasks.

Diagnosis:

Injury risk associated with manic conduct.

Self-harm risk associated with depressed episodes.

Inability to cope due to changes in behavior and mood.

Impaired social interaction brought on by mood fluctuations and behavioral changes.

Planning:

By keeping an eye on the patient’s behavior and adopting safety measures to avoid harm, you can make sure they’re safe.

Create a plan to avoid suicide for the patient, and keep a watchful eye out for any indications of self-harm.

Enlighten the patient’s coping mechanisms so they can control their mood swings and behavioral changes.

Nonetheless, foster social connection, motivate the patient to take part in social activities.

Interventions:

To control the patient’s symptoms, administer drugs as directed.

Use cognitive-behavioral therapy to assist the patient in developing symptom management and coping mechanisms.

To improve their social relations, encourage the patient to take part in social events and support groups.

Teach the patient relaxing strategies to assist them control their symptoms, such as deep breathing and meditation.

Evaluation:

By keeping a close eye on the patient’s attitude, actions, and cognitive patterns, you may assess how well the nursing care plan is working.

To safeguard the patient’s physical health, track their vital signs and test results.

Assess the patient’s capacity to control their symptoms and mood swings.

Lastly, determine the patient’s propensity for social contact and functional capacity.

Care Plan for Bowel Obstruction

For intestinal obstruction, a nursing care plan would normally contain the following:

The patient’s bowel movements, vomiting, nausea, abdominal distention, and intensity of pain should all be evaluated. Keep track of any changes in the patient’s condition and inform the doctor as necessary.

Administering recommended medications such bowel-moving aids, stool softeners, and analgesics. To help the patient feel more at ease and stay hydrated, provide them dental care. To reduce the pressure on the abdomen, help the patient maintain a semi-position. fowler’s

Monitoring: Keep an eye on the patient’s vital signs, food and fluid intake, and abdominal bloating. Keep track of any changes in the patient’s condition and inform the doctor as necessary.

Education: Inform the patient about the value of maintaining bowel regularity and offer advice on dietary modifications that could help avoid bowel blockages in the future.

Collaborate cooperatively with the patient’s doctor, nutritionist, and other medical professionals to ensure thorough and well-coordinated care.

Assessment: Assess the success of therapies and record the patient’s reaction to care. Depending on the patient’s progress—or lack thereof—modify the treatment plan as necessary.

In addition to managing the patient’s symptoms, avoiding complications, and fostering healing and recovery are the main objectives of nursing care for intestinal obstruction.

Care Plan for Heart Failure

The following elements are frequently included in a nursing care plan for heart failure:

Assessment:

Assess the patient’s cardiac condition thoroughly, taking note of their vital signs, heartbeat, breathing rate, and peripheral edema.

Analyze the patient’s medical background, taking into account any previous diagnoses, prescriptions taken today, and previous surgeries.

Examine the patient’s fluid intake and output, and keep track of any weight changes.

Analyze the patient’s activity level and any restrictions.

To ascertain the patient’s mental state and level of comprehension of their illness, do a psychological evaluation.

Diagnosis:

Reduced cardiac output-related impaired gas exchange

Excessive fluid volume and compromised cardiac function

Activity Intolerance brought on by a drop in cardiac output

Anxiety brought on by modifications in health status

Planning:

Frequent monitoring of oxygen saturation levels and vital indicators

As directed, administer oxygen therapy

Diuretics and other drugs should be taken as directed.

Track fluid intake and outflow, and make any required adjustments to the patient’s fluid balance.

As tolerated, help the patient to engage in modest exercise.

Support the sufferer and their family members emotionally

Provide the patient information about their disease and guidelines for self-care at home.

Interventions:

Provide prescription drugs such diuretics, ACE inhibitors, beta-blockers, and vasodilators as directed.

Keep an eye on how the patient responds to the drug and change the dosage as necessary.

Track fluid intake and outflow, and make any required adjustments to the patient’s fluid balance.

As tolerated, advise the patient to engage in modest exercise.

As necessary, deliver oxygen treatment while keeping an eye on the patient’s oxygen saturation levels.

Counsel the patient and their kin and offer emotional support

Inform the patient about their illness, including any necessary food restrictions, medication compliance, and lifestyle changes.

Evaluation:

Analyze the patient’s reaction to therapy and make any required adjustments to the care plan.

Keep a regular eye on the patient’s vitals, fluid balance, and oxygen saturation levels.

Track the patient’s activity level and advancement toward meeting their activity goals.

Assess the patient’s emotional well-being and amount of knowledge regarding their illness.

To promote a smooth transition to home care, give the patient and their family members regular education and support.

Nursing Care Plan Writing Service

nursesessay.com is best known for their expertise in writing nursing care plan template. Therefore, we would be pleased to assist you in drafting a nursing care plan template. To get you started, follow these steps:

Beginning with an assessment of your patient’s health, consider their medical background, present symptoms, vital signs, and any pertinent lab or imaging results.

 

  • Diagnose: Determine the nursing diagnosis or issue based on your evaluation. When choosing a suitable nursing diagnosis, you can use the NANDA-I taxonomy as guidance.
  • Planning: Create a plan of care for your patient that includes SMART (specific, measurable, achievable, relevant, and time-bound) objectives. Consider the patient’s needs and ethnic heritage when formulating the plan.
  • Implementation: Put your planned interventions into action. Recording the interventions and the patient’s reaction to them is important.
  • Evaluation: Assess the success of your interventions in meeting the objectives of the patient. If the objectives weren’t met, adjust your plan as necessary.
  • Be keen to include the following parts while creating the nursing care plan:
  • Patient data: This comprises the patient’s name, age, sexual orientation, past health conditions, and present symptoms.
  • Nursing diagnostic: Describe the issue or nursing diagnosis you have located.
  • List the SMART objectives you’ve created for your patient.
  • Explain the interventions you’ll use to carry out the objectives.
  • Evaluation: Describe the process you’ll use to gauge the success of your initiatives.
  • Documentation: Keep a record of the interventions you’ve used and how well the patient has responded to them.

Conclusion

In conclusion, do not forget to include the patient’s family in the care plan and to speak to them in a clear and concise manner. More so, you may build a thorough nursing care plan with the help of numerous internet resources, including nursing care plan templates, tutorials, and samples.

You might also think about hiring a nursing care plan writing service if you’re having trouble coming up with one. These services are offered by qualified writers with experience in nursing who can assist you in developing a high-quality nursing care plan that adheres to your patient’s particular needs.

Lastly, it is crucial to keep in mind that a nursing care plan is an important part of patient care and should be thorough, accurate, and tailored to the patient’s requirements. You must make sure that your nursing care plan is well-written, understandable, and succinct.

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