 |
 |
 |
Download nursing care plan template in Microsoft Word format.
Patient Assessment Using a Nursing Care Plan Template
Are you are a nurse or nursing student who needs to develop a realistic model of a nursing care plan? Would it be helpful if there were a nursing care plan template to help you with this task?—a template with the proper format and all the appropriate topics covered? Developing a care plan can be a difficult assignment, especially without a quality example to which you can refer. Fortunately there are many such templates available online, some at absolutely no cost. In this article we will first describe what a nursing care plan is intended for, followed by a brief outline of the format these plans usually take and a list of the topics that should always be included in a nursing care plan template.
What Is a Nursing Care Plan?
A nursing care plan is a document used by nurses to help them with patient evaluation. Most commonly used in emergency room situations, these forms are the primary assessment vehicle for nurses, who use them to develop a preliminary nurse’s diagnosis and tentative treatment plan, as well as helping them to prioritize patient care to ensure the most serious cases are seen by the doctor first.
The ability to properly write a nursing care plan is one of the main requirements that will have to be met by student nurses, and an activity they will perform countless times before graduation. Collectively, these forms test a nurse’s investigative and assessment ability, as well as their ability to think critically and logically in an emergency situation.
Nursing Care Plan Template: What Should Be Included?
The format of a nursing care plan will vary slightly depending on the hospital or nursing school, but regardless of the format used, there are certain items or topics that should always be addressed. Some of these include:
• Patient’s Name and Information. The name of the patient and all of his/her identifying information such as age, sex, height and weight should always be addressed.
• Diagnostic Information. The results of appropriate diagnostic tests, tests which determine things like blood pressure, pulse and respiration should also be included.
• Patient’s Symptoms. If the patient is responsive you should always include his/her explanation of the symptoms. This section is one of the most important, which is why any clarifying questions you can use to narrow these symptoms down are crucial.
• History. A patient’s history will include items such as previous illnesses or surgeries, family history of illness or disease and any allergies to medication.
• Nurse’s Diagnosis. Based on the objective and subjective data collected, a nurse should be able to develop a preliminary nurse’s diagnosis. This, of course, is not the final diagnosis, but it can help to determine patient priority and can alert doctors to any potential complications.
• Patient Priority. Patient priority is usually reflected on a scale from 1-5, with “1” meaning a very low priority and “5” meaning the patient should be dealt with immediately.
• Signature and Date. By signing and dating the nursing care plan, you are confirming that all the data on the form is true and correct to the best of your knowledge.
A nursing care plan template is ideal for student nurses who need practice in filling out these forms correctly, because once the data has been entered for one patient, the template can easily be reset to practice once again.