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Nursing Care Plans
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Using Nursing Care Plans in Clinicals

Using Nursing Care Plans in Clinicals

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Study Tools For Using Nursing Care Plans in Clinicals

Nursing Concept Map Template (Cheatsheet)
Care Plan Template (Cheatsheet)
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Outline

Overview

  1. What does this look like OUTSIDE of school?
  2. How to practicing nurses utilize Nursing Care Plans?

Nursing Points

General

  1. Most often NOT written
    1. Though some EMR’s require documentation
      1. IPOC = “Interdisciplinary Plan of Care”
    2. Check facility policy
  2. Happens by Instinct
    1. Nursing process + Critical thinking
    2. May not even realize what’s happening
  3. Examples
    1. Get report –> “blanchable redness on the sacrum”
      1. Immediately in your brain –> Skin!!
        1. Make sure you turn q2h
        2. Use barrier cream if they’re incontinent
        3. Careful when repositioning
        4. Make sure it’s still blanching at end of shift (or decreased)
    2. Get report –> “+3 pitting edema and 1+ pulses in the feet”
      1. Immediately –> There’s a perfusion issue!
        1. Keep the feet elevated
        2. Assess edema and pulses
        3. Ambulate as able
        4. Evaluate blood pressure
        5. Possibly administer diuretics?
        6. Make sure it’s not worse by end of day
  4. You may not fill out a form, but you are STILL planning nursing care
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Transcript

Okay guys, I’m excited to talk to you about what this Nursing Care Plan process really looks like in the clinical setting.

We talked about this in the first lesson, it’s so frustrating to hear nurses say things like “you’ll never using Nursing Care Plans in real life”… it makes you feel like you’re wasting your time, right!?  Well what’s really happening is they’re just not doing it the same way you are doing it in school. I promise you, it’s still happening, it just doesn’t look the same. So I just want to reassure you guys of how important understanding Nursing Care Planning is and what it looks like in real life!

So, here’s the big thing to know – in actual clinical practice, most of the time we aren’t actually filling out any kind of template or form. It’s usually not written. Now, the one caveat to that is that there are some EMR’s or Electronic Medical Records that actually have a place to document your care plan – sometimes it’s even called the IPOC, which stands for interdisciplinary plan of care.  A lot of times they’ll have a set of predetermined priorities with assessments, interventions, and goals that you can just check the boxes and say “yep, this is what we’ll do for this patient”. So – really just make sure you check your facility policy to see if there’s actually something you have to document.

So, if we’re not filling out forms and templates and we’re not actually putting this on paper. What’s actually happening? Well, what you’re seeing is the SAME process happening by INSTINCT!  It’s just the nursing process, plus critical thinking, and maybe a little bit of experience thrown in, right? The truth is that these nurses who say “oh, you’ll never use a care plan in real life” actually just don’t realize they are doing it!! Let me give you some examples of what I mean.

You walk in for your shift and you’re getting report and the offgoing nurse says “oh, this patient has some blanchable redness on the sacrum” – so that means they’ve got some redness, but if you press your finger into it, it turns white – or blanches – that means it’s NOT a pressure ulcer… YET.  So what happens in the nurse’s brain? That nurse is immediately gonna go – OH – a skin issue! I need to make sure I turn every 2 hours, might need to use some barrier cream, especially if they’re incontinent. I should probably be careful when I’m repositioning them so we don’t add any friction or shear – and I’m gonna keep a close eye on it to make sure it’s still blanching and not getting worse.  Right? ALL of that happens in their head all at once, and all by instinct. They have data – they recognized a problem – they decided what to do about it and why – and they knew what to look for to make sure their interventions were effective. That’s a care plan! Let’s look at another one.

You get report that the patient has 3+ pitting edema and only +1 pulses in their feet. So right away, your brain goes – oh, dang! There’s some perfusion issues there. Let me make sure I keep their legs elevated, I may even try to get them up and walking around if possible. Oh, and I’ll see if the provider thinks some diuretics might be appropriate depending on what they’ve got going on. And, of course I’m going to be assessing that edema and those pulses to make sure it doesn’t get worse – I might even get a doppler to confirm the pulse, right? And of course, we know this might be cardiac related, so I’m gonna make sure I keep an eye on their blood pressure, too, right?  See? It all happens subconsciously!

So, remember, while that nursing care plan may not actually be written down in any kind of special template – it is STILL happening. It’s just that it’s happening by instinct and subconsciously most of the time.  The biggest thing I’ll say here, is always trust your gut about what needs to be part of the plan and loop anyone else in as needed. If you need a respiratory therapist, call them, if you need PT’s input, grab them when they come on the unit, if you think you need provider orders, call the provider. Trust your instincts when you’re planning the best care for your patient.

So in the rest of this course, we’re actually going to use the 5-step process we talked about to work you through some examples of common disease processes and how to put together care plans for those patients – so make sure you check those out. Now, go out and be your best selves today. And, as always, happy nursing!

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Nursing Care Plans

How do I write a Nursing Care Plan? Why and how do we even use Nursing Care Plans? Sound familiar?

Our Nursing Care Plan Course will answer those questions and help you understand the most effective way to write a Nursing Care Plan including how to write a nursing diagnosis, interventions, and more. PLUS, we are going to give you examples of Nursing Care Plans for all the major body systems and some of the most common disease processes. The course also includes a nursing care plan template that you can use to quickly complete care plans. When you complete this course, you will be able to write and implement powerful and effective Nursing Care Plans.

Course Lessons

Nursing Care Plans Course Introduction
Nursing Care Plans Course Introduction
Understanding Nursing Care Plans
Purpose of Nursing Care Plans
How to Write a Nursing Care Plan
Using Nursing Care Plans in Clinicals
Cardiovascular (Cardiac, CVD) Care Plans
Nursing Care Plan (NCP) for Angina
Nursing Care Plan (NCP) for Atrial Fibrillation (AFib)
Nursing Care Plan (NCP) for Aortic Aneurysm
Nursing Care Plan (NCP) for Arterial Disorders
Nursing Care Plan (NCP) for Cardiogenic Shock
Nursing Care Plan (NCP) for Cardiomyopathy
Nursing Care Plan (NCP) for Congenital Heart Defects
Nursing Care Plan (NCP) for Congestive Heart Failure (CHF)
Nursing Care Plan (NCP) for Endocarditis
Nursing Care Plan (NCP) for Gestational Hypertension, Preeclampsia, Eclampsia
Nursing Care Plan (NCP) for Heart Valve Disorders
Nursing Care Plan (NCP) for Hypertension (HTN)
Nursing Care Plan (NCP) for Marfan Syndrome
Nursing Care Plan (NCP) for Myocardial Infarction (MI)
Nursing Care Plan (NCP) for Pericarditis
Nursing Care Plan (NCP) for Thrombophlebitis / Deep Vein Thrombosis (DVT)
Nursing Care Plan (NCP) for Decreased Cardiac Output
Nursing Care Plan (NCP) for Activity Intolerance
Nursing Care Plan for Coronary Artery Disease (CAD)
Nursing Care Plan for Myocarditis
Nursing Care Plan for Distributive Shock
Eyes, Ears, Nose, Throat (EENT) Care Plans
Nursing Care Plan (NCP) for Cleft Lip / Cleft Palate
Nursing Care Plan (NCP) for Epiglottitis
Nursing Care Plan (NCP) for Glaucoma
Nursing Care Plan (NCP) for Infective Conjunctivitis / Pink Eye
Nursing Care Plan (NCP) for Otitis Media / Acute Otitis Media (AOM)
Nursing Care Plan (NCP) for Tonsillitis
Nursing Care Plan for Macular Degeneration
Nursing Care Plan (NCP) for Meniere’s Disease
Nursing Care Plan for Nasal Disorders
Gastrointestinal (GI) Care Plans
Nursing Care Plan (NCP) for Abdominal Pain
Nursing Care Plan (NCP) for Appendicitis
Nursing Care Plan (NCP) for Celiac Disease
Nursing Care Plan (NCP) for Cholecystitis
Nursing Care Plan for Cirrhosis (Liver)
Nursing Care Plan (NCP) for Constipation / Encopresis
Nursing Care Plan (NCP) for Diverticulosis / Diverticulitis
Nursing Care Plan (NCP) for Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder)
Nursing Care Plan (NCP) for Epiglottitis
Nursing Care Plan (NCP) for Gastroesophageal Reflux Disease (GERD)
Nursing Care Plan (NCP) for Hyperemesis Gravidarum
Nursing Care Plan (NCP) for Imperforate Anus
Nursing Care Plan (NCP) for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
Nursing Care Plan (NCP) for Intussusception
Nursing Care Plan (NCP) for Omphalocele
Nursing Care Plan (NCP) for Pancreatitis
Nursing Care Plan (NCP) for Peptic Ulcer Disease (PUD)
Nursing Care Plan (NCP) for Vomiting / Diarrhea
Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed
Nursing Care Plan (NCP) for Bowel Obstruction
Nursing Care Plan for Hiatal Hernia
Nursing Care Plan for Gastritis
Nursing Care Plan for Hemorrhoids
Genitourinary (Renal) (Kidney) (Nephrotic) Care Plans
Nursing Care Plan (NCP) for Acute Kidney Injury
Nursing Care Plan (NCP) for Benign Prostatic Hyperplasia (BPH)
Nursing Care Plan (NCP) for Chronic Kidney Disease
Nursing Care Plan (NCP) for Enuresis / Bedwetting
Nursing Care Plan (NCP) for Glomerulonephritis
Nursing Care Plan (NCP) for Nephrotic Syndrome
Nursing Care Plan (NCP) for Renal Calculi
Nursing Care Plan (NCP) for Urinary Tract Infection (UTI)
Nursing Care Plan for Herpes Simplex (HSV, STI)
Nursing Care Plan for Gonorrhea (STI)
Nursing Care Plan for Chlamydia (STI)
Nursing Care Plan for Syphilis (STI)
Nursing Care Plan for Testicular Torsion
Nursing Care Plan (NCP) for Epididymitis
Hematology (Blood, labs), Oncology (Cancer) & Immunology (Immunity) Care Plans
Nursing Care Plan (NCP) for Acquired Immune Deficiency Syndrome (AIDS)
Nursing Care Plan (NCP) for Anemia
Nursing Care Plan (NCP) for Disseminated Intravascular Coagulation (DIC)
Nursing Care Plan (NCP) for Dehydration & Fever
Nursing Care Plan (NCP) for Hemophilia
Nursing Care Plan (NCP) for Herpes Zoster – Shingles
Nursing Care Plan (NCP) for Hepatitis
Nursing Care Plan (NCP) for Leukemia
Nursing Care Plan (NCP) for Lyme Disease
Nursing Care Plan (NCP) for Lymphoma (Hodgkin’s, Non-Hodgkin’s)
Nursing Care Plan (NCP) for Neutropenia
Nursing Care Plan (NCP) for Sickle Cell Anemia
Nursing Care Plan (NCP) for Skin cancer – Melanoma, Basal Cell Carcinoma, Squamous Cell Carcinoma
Nursing Care Plan (NCP) for Thrombocytopenia
Nursing Care Plan (NCP) for Varicella / Chickenpox
Nursing Care Plan (NCP) for Hypoglycemia
Total Iron Binding Capacity (TIBC) Lab Values
Nursing Care Plan for Scleroderma
Nursing Care Plan for Fibromyalgia
Nursing Care Plan for Liver Cancer
Nursing Care Plan (NCP) for Stomach Cancer (Gastric Cancer)
Nursing Care Plan (NCP) for Kidney Cancer
Nursing Care Plan (NCP) for Bladder Cancer
Nursing Care Plan (NCP) for Thyroid Cancer
Nursing Care Plan (NCP) for Bone Cancer (Osteosarcoma, Chondrosarcoma, and Ewing Sarcoma)
Nursing Care Plan (NCP) for Lung Cancer
Nursing Care Plan (NCP) for Prostate Cancer
Nursing Care Plan (NCP) for Testicular Cancer
Nursing Care Plan (NCP) for Colorectal Cancer (Colon Cancer)
Nursing Care Plan (NCP) for Breast Cancer
Nursing Care Plan (NCP) for Cervical Cancer
Nursing Care Plan (NCP) for Ovarian Cancer
Integumentary (Skin) Care Plans
Nursing Care Plan (NCP) for Burn Injury (First, Second, Third degree)
Nursing Care Plan (NCP) for Eczema (Infantile or Childhood) / Atopic Dermatitis
Nursing Care Plan (NCP) for Impetigo
Nursing Care Plan (NCP) for Pressure Ulcer / Decubitus Ulcer (Pressure Injury)
Nursing Care Plan (NCP) for Skin cancer – Melanoma, Basal Cell Carcinoma, Squamous Cell Carcinoma
Nursing Care Plan (NCP) for Cellulitis
Nursing Care Plan (NCP) for Psoriasis
Mental Health Care Plans
Nursing Care Plan (NCP) for Alcohol Withdrawal Syndrome / Delirium Tremens
Nursing Care Plan (NCP) for Alzheimer’s Disease
Nursing Care Plan for (NCP) Autism Spectrum Disorder
Nursing Care Plan (NCP) for Dissociative Disorders
Nursing Care Plan (NCP) for Anxiety
Nursing Care Plan (NCP) for Mood Disorders (Major Depressive Disorder, Bipolar Disorder)
Nursing Care Plan (NCP) for Paranoid Disorders
Nursing Care Plan (NCP) for Personality Disorders
Nursing Care Plan (NCP) for Post-Traumatic Stress Disorder (PTSD)
Nursing Care Plan (NCP) for Schizophrenia
Nursing Care Plan (NCP) for Somatic Symptom Disorder (SSD)
Nursing Care Plan (NCP) for Suicidal Behavior Disorder
Nursing Care Plan (NCP) for Dementia
Nursing Care Plan (NCP) for Depression
Nursing Care Plan (NCP) for Attention Deficit Hyperactivity Disorder (ADHD)
Metabolic & Endocrine Care Plans
Nursing Care Plan (NCP) for Addison’s Disease (Primary Adrenal Insufficiency)
Nursing Care Plan (NCP) for Diabetes
Nursing Care Plan (NCP) for Diabetes Insipidus
Nursing Care Plan (NCP) for Diabetic Ketoacidosis (DKA)
Nursing Care Plan (NCP) for Diabetes Mellitus (DM)
Nursing Care Plan (NCP) for Hypothyroidism
Nursing Care Plan (NCP) for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
Nursing Care Plan (NCP) for Hyperthyroidism
Nursing Care Plan (NCP) for Myasthenia Gravis (MG)
Nursing Care Plan (NCP) for Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Nursing Care Plan (NCP) for Systemic Lupus Erythematosus (SLE)
Nursing Care Plan (NCP) for Hypoglycemia
Nursing Care Plan (NCP) for Fluid Volume Deficit
Nursing Care Plan (NCP) for Nutrition Imbalance
Nursing Care Plan (NCP) for Hypoparathyroidism
Nursing Care Plan (NCP) for Hyperparathyroidism
Nursing Care Plan (NCP) for Hashimoto’s Thyroiditis
Nursing Care Plan (NCP) for Hyperthermia (Thermoregulation)
Neurological Care Plans
Nursing Care Plan (NCP) for Alzheimer’s Disease
Nursing Care Plan (NCP) for Brain Tumors
Nursing Care Plan (NCP) for Cerebral Palsy (CP)
Nursing Care Plan (NCP) for Encephalopathy
Nursing Care Plan (NCP) for Hydrocephalus
Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)
Nursing Care Plan (NCP) for Meningitis
Nursing Care Plan (NCP) for Multiple Sclerosis (MS)
Nursing Care Plan (NCP) for Neural Tube Defect, Spina Bifida
Nursing Care Plan (NCP) for Parkinson’s Disease
Nursing Care Plan (NCP) for Seizures
Nursing Care Plan (NCP) for Spinal Cord Injury
Nursing Care Plan (NCP) for Stroke (CVA)
Nursing Care Plan (NCP) for Syncope (Fainting)
Nursing Care Plan (NCP) for Migraines
Nursing Care Plan for (NCP) Trigeminal Neuralgia
Nursing Care Plan (NCP) for Guillain-Barre
Nursing Care Plan (NCP) for Bell’s Palsy
Nursing Care Plan (NCP) for West Nile Virus
Obstetrics (OB) & Pediatrics (Peds) Care Plans
Nursing Care Plan (NCP) for Abortion, Spontaneous Abortion, Miscarriage
Nursing Care Plan (NCP) for Abruptio Placentae / Placental abruption
Nursing Care Plan for (NCP) Autism Spectrum Disorder
Nursing Care Plan (NCP) for Bronchiolitis / Respiratory Syncytial Virus (RSV)
Nursing Care Plan (NCP) for Cerebral Palsy (CP)
Nursing Care Plan (NCP) for Chorioamnionitis
Nursing Care Plan (NCP) for Cleft Lip / Cleft Palate
Nursing Care Plan (NCP) for Clubfoot
Nursing Care Plan (NCP) for Congenital Heart Defects
Nursing Care Plan (NCP) for Cystic Fibrosis
Nursing Care Plan (NCP) for Disseminated Intravascular Coagulation (DIC)
Nursing Care Plan (NCP) for Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder)
Nursing Care Plan (NCP) for Ectopic Pregnancy
Nursing Care Plan (NCP) for Enuresis / Bedwetting
Nursing Care Plan for (NCP) Fetal Alcohol Syndrome (FAS)
Nursing Care Plan (NCP) for Imperforate Anus
Nursing Care Plan (NCP) for Incompetent Cervix
Nursing Care Plan (NCP) for Infective Conjunctivitis / Pink Eye
Nursing Care Plan (NCP) for Intussusception
Nursing Care Plan (NCP) for Marfan Syndrome
Nursing Care Plan (NCP) for Mastitis
Nursing Care Plan (NCP) for Meconium Aspiration
Nursing Care Plan (NCP) for Pediculosis Capitis / Head Lice
Nursing Care Plan (NCP) for Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM)
Nursing Care Plan (NCP) for Phenylketonuria (PKU)
Nursing Care Plan (NCP) for Postpartum Hemorrhage (PPH)
Nursing Care Plan (NCP) for Preterm Labor / Premature Labor
Nursing Care Plan (NCP) for Reye’s Syndrome
Nursing Care Plan (NCP) for Rheumatic Fever
Nursing Care Plan (NCP) for Newborns
Nursing Care Plan for Endometriosis
Nursing Care Plan for Pelvic Inflammatory Disease (PID)
Nursing Care Plan (NCP) for Polycystic Ovarian Syndrome (PCOS)
Nursing Care Plan (NCP) for Maternal-Fetal Dyad Using GTPAL
Nursing Care Plan for Newborn Reflexes
Nursing Care Plan (NCP) for Mumps
Nursing Care Plan (NCP) for Rubeola – Measles
Nursing Care Plan (NCP) for Acute Bronchitis
Nursing Care Plan (NCP) for Gestational Diabetes (GDM)
Nursing Care Plan (NCP) for Process of Labor
Nursing Care Plan (NCP) for Transient Tachypnea of Newborn
Nursing Care Plan (NCP) for Placenta Previa
Nursing Care Plan (NCP) for Dystocia
Nursing Care Plan (NCP) for Neonatal Jaundice | Hyperbilirubinemia
Respiratory Care Plans
Nursing Care Plan (NCP) for Acute Respiratory Distress Syndrome
Nursing Care Plan (NCP) for Anaphylaxis
Nursing Care Plan (NCP) for Aspiration
Nursing Care Plan (NCP) for Asthma
Nursing Care Plan (NCP) for Asthma / Childhood Asthma
Nursing Care Plan (NCP) for Blunt Chest Trauma
Nursing Care Plan (NCP) for Bronchoscopy (Procedure)
Nursing Care Plan (NCP) for Bronchiolitis / Respiratory Syncytial Virus (RSV)
Nursing Care Plan (NCP) for Chronic Obstructive Pulmonary Disease (COPD)
Nursing Care Plan (NCP) for Emphysema
Nursing Care Plan (NCP) for Influenza
Nursing Care Plan (NCP) for Meconium Aspiration
Nursing Care Plan (NCP) for Pertussis / Whooping Cough
Nursing Care Plan (NCP) for Pneumonia
Nursing Care Plan (NCP) for Pneumothorax/Hemothorax
Nursing Care Plan (NCP) for Respiratory Failure
Nursing Care Plan (NCP) for Restrictive Lung Diseases
Nursing Care Plan (NCP) for Thoracentesis (Procedure)
Nursing Care Plan (NCP) for Tuberculosis
Nursing Care Plan (NCP) for Pulmonary Embolism
Nursing Care Plan (NCP) for Impaired Gas Exchange
Nursing Care Plan for Pulmonary Edema
Nursing Care Plan for Restrictive Lung Diseases (Pulmonary Fibrosis, Neuromuscular Disorders)
Sepsis (Septic) & Shock Care Plans
Nursing Care Plan (NCP) for Cardiogenic Shock
Nursing Care Plan (NCP) for Hypovolemic Shock
Nursing Care Plan (NCP) for Sepsis
Nursing Care Plan (NCP) for Acute Pain
Nursing Care Plan (NCP) for Infection
Musculoskeletal and Skeletal (Osteo) (Bones) Care Plans
Nursing Care Plan (NCP) for Clubfoot
Nursing Care Plan (NCP) for Gout / Gouty Arthritis
Nursing Care Plan (NCP) for Scoliosis
Nursing Care Plan (NCP) for Skull Fractures
Nursing Care Plan (NCP) for Osteoarthritis (OA), Degenerative Joint Disease
Nursing Care Plan (NCP) for Osteoporosis
Nursing Care Plan (NCP) for Rhabdomyolysis
Nursing Care Plan (NCP) for Rheumatoid Arthritis (RA)
Nursing Care Plan (NCP) for Risk for Fall
Nursing Care Plan for Fractures
Nursing Care Plan for Amputation
Nursing Care Plan for Compartment Syndrome
Nursing Care Plan for Osteomyelitis