Designing nursing interventions

The development of nursing interventions that demonstrate the link between nursing actions and patient outcomes is a high priority for nursing research. The development of intervention research frequently focuses on the methods used to test the intervention while less attention is placed on rigor in intervention development and design. The purpose of this paper is to provide thinking points for researchers considering the development of nursing interventions. The thinking points were developed from the limited literature on this topic in synthesis with the authors own experiences of designing nursing interventions. Adoption of a systematic approach to intervention testing is advocated along with a step-wise intervention development process. This process calls for attention to problem definition, conceptual underpinnings, desired outcomes and measures and evidence-based content along with careful consideration of delivery methods, dose and attention to protecting the integrity of the intervention during testing. The approach advocated will help to ensure that nursing intervention research makes a useful contribution to the development of nursing practice. © 2007 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). 

https://www.collegianjournal.com/article/S1322-7696(07)00003-0/pdf

What Is a Nursing Intervention?

According to the Journal of Nursing Education, nursing interventions can be described as one of two ideas:

§  Any task that a nurse does to or for a patient.

§  Anything a nurse does that leads directly to a patient outcome.

These tasks may be general or specific and direct or indirect. Examples of areas of patient care interventions include:

§  Sleep pattern control

§  Mobility therapy

§  Compliance with diet

§  Infection control

§  Alcohol abuse control

§  Positioning therapy

§  Bedbound care

§  Energy conservation

§  Postpartum care

Nurses may work in specialized settings (i.e. ICU, oncology, pediatrics), which may require knowledge of specific interventions unnecessary in other areas. Although every nurse may not be familiar with every intervention, the concept remains universal across the field.

Nursing Intervention vs. Nursing Assessment

Nursing interventions are often confused with nursing assessments. Although both are essential aspects of a nurse’s work, the practices are distinct.

Assessments may be done by both nurses and physicians. They are how medical personnel gain information about a patient’s symptoms and ailments. According to AMN (American Mobile Nurses) Healthcare Education Services, there are four types of possible assessments:

§  Comprehensive health assessments, which require a thorough review of a patient’s health.

§  Abbreviated assessments, which are done when lengthy evaluations are not required.

§  Problem-focused assessments, which are designed to focus on a specific ailment or medical issue.

§  Assessment for special populations, which are used for medically significant groups of people, such as infants or the elderly.

During assessments, nurses may gather information about:

§  Patient health history

§  Chief complaints

§  Present health status

§  Condition of external body areas such as the skin

§  Neurological conditions

§  Condition of internal systems such as cardiovascular, pulmonary or musculoskeletal

§  Patient nutrition

Nursing interventions are informed by the results of nursing assessments. While the ultimate goal of an assessment is to decide on a course of treatment, an intervention in many cases is the treatment. Nursing interventions also go beyond simply “fixing” a patient medically. These actions can include:

§  Crisis therapy and stress control

§  Terminal care and hospice

§  Bereavement support

§  Meals on Wheels

§  Communicating with nurses and physicians

§  Coordinating nursing care and conducting status reports

§  Universal health precautions

Because nursing interventions describe nearly every interaction nurses have with patients, a thorough system is used to identify and evaluate their work.

Understanding the Nursing Interventions Classification System

The Nursing Interventions Classification (NIC) system is designed to categorize and describe every possible intervention a nurse might perform. This system is constantly used, evaluated and updated. Nursing Interventions Classification (NIC) 6th Edition describes a number of uses for the system. They include:

§  Clinical documentation

§  Standardized communication regarding care

§  Research on intervention effectiveness

§  Productivity measurement

§  Evaluations of competency

§  Curriculum design

According to the U.S. National Library of Medicine, the system contains several levels of classification. The first level consists of seven broad domains:

§  Behavioral

§  Community

§  Family

§  Health System

§  Physiological: Basic

§  Physiological: Complex

§  Safety

Within these domains are 30 classes, followed by lists of the interventions themselves. There are currently 554 interventions in total.

Although the sheer number of interventions may seem daunting, it is important to remember that most nurses do not need to be familiar with or use all the interventions.

Your Future in Nursing

As a system that helps nurses both understand and improve the quality of care, nursing interventions are an occupational mainstay. For practicing nurses seeking to further develop their knowledge base, the RN to BSN online program at Husson University provides an exceptional curriculum designed to transform careers. Because the program is offered fully online, working professionals can earn their degree in a format designed for their life.

https://online.husson.edu/nursing-interventions-nic-system/

 

What is a nursing note?

A nursing note is a medical note into a medical or health record made by a nurse that can provide an accurate reflection of nursing assessments, changes in patient conditions, care provided and relevant information to support the clinical team to deliver excellent care.

Complete and accurate nursing notes are crucial to make good decisions for patient care. Nursing notes should provide a clear and accurate picture of the patient while under the care of the healthcare team. Federal, state, and institutional regulations require that nursing notes follow broad guidelines to determine if a nurse’s action was reasonable and prudent.

What does a nursing note consist of?

In addition, to the type of information found on the medical note page, nursing notes should follow these guidelines:

• Always include interventions initiated and the patient response when documenting an acute abnormality found during assessment
• Always elaborate when documenting a body system abnormality with each assessment
• Always include if an assessment was visual, audible, and/or tactile
• Reconcile mismatched objective and subjective assessment findings
• Document the patient’s baseline mental status
• Always assess the patient at the time of discharge or transfer.
• Use quantifiable data with descriptions. Reference to common objects, such as a quarter or soda can, to describe the size or shape of wounds may be useful with awkward shapes or when there isn’t access to a measurement device.

How will nursing notes be used?

Nursing notes can be used for various purposes from assessing proper medical care to malpractice litigation. Thus it is important that nurses write their nursing notes with various audiences in mind:

• The Healthcare Team: Nursing notes provide a healthcare team a complete and accurate timeline of a patient’s health status and care. This is key to determining a diagnosis and further care.
• The Nurse: Nursing notes should be complete enough to jog a nurse’s memory if any details are not clear or hazy. In the unfortunate case that a nurse must testify for a lawsuit, clear and accurate nursing notes serve to ensure the details of a nurses care.
• The Lawyers, Judge, and Jury: Clear, comprehensive nursing notes ensure if our judicial system can determine if a patient’s nursing care was reasonable and prudent.

How an Electronic Health Record can help

An electronic health record, or EHR, is set up to ensure that nursing notes are complete and accurate. With good EHR software and EHR systems, nurses will be alerted to any missing, incomplete, or possibly inaccurate nursing notes.

An EHR also guarantees all of a patient’s nursing notes are never lost and stored in one easy to access location. Professionals can make sure they have all the information to provide the best care possible, and patients can make sure they always have access to all their nursing notes.

Check out Practice Fusion’s EHR system to guarantee complete and accurate nursing notes and cloud-based storage for easy access.

https://www.practicefusion.com/nursing-notes/

Tips for Writing Quality Nurse Notes

Taking accurate nurses notes is one of the most important parts of caring for a patient. Nothing matters more than providing clear and detailed information about a patient's condition and their symptoms on their chart. Your observations make it easier to determine what medical treatments a patient needs without serious mistakes being made.

You should keep in mind a few core guidelines when you write notes on any patient:

Always use a consistent format: Make a point of starting each record with patient identification information. Each entry should also include your full name, the date and the time of the report.

Keep notes timely: Write your notes within 24 hours after supervising the patient's care. Writing down your observations and noting care given must be done while it is fresh in your memory, so no faulty information is passed along.

Use standard abbreviations: Write out complete terms whenever possible. If you must use an abbreviation, stick to standard medical abbreviations familiar to other nurses or the attending physician.

Remain objective: Write down only what you see and hear. Avoid noting subjective comments or giving your own interpretation on the patient's condition.

Note all communication: Jot down everything important you hear regarding a patient's health during conversations with family members, doctors and other nurses. This will ensure all available information on the patient has been charted. Always designiate communication with quotation marks.

Ignore trivial information: Everything included in your nurses notes should directly relate to your patient's health. Do not note information on your chart that does not pertain to their immediate care.

Keep it simple: Notes are not meant to be a work of art. They are designed to be quickly read, so nurses and doctors on the next shift can be caught up to speed on a patient. Focus only on specific information relevant to symptoms you are charting. Do not go into depth on the patient's medical history.

Write clearly: When you do handwritten notes, make an effort to keep your handwriting clear and readable. Illegible handwriting can lead to a patient receiving the wrong medication or an incorrect dosage of the right medication. This can have serious, or even fatal, consequences.

Standard nurses notes usually include an opening note, middle notes and a closing note. In these notes, you should note any primary or secondary problems a patient is experiencing. Record things like blood pressure, heart rate and skin color that can offer insight into these issues.

Make a record of any assessments you have administered during your shift. Indicate if more tests are needed and include a probable diagnosis of their condition.

Always note what medications the patient has been prescribed. List all medications the patient has been given, along with dosage and how the medicine was administered.

https://www.fastaff.com/blogs/tips-writing-quality-nurse-notes

Nursing documentation

Introduction

• Aim

  Definition of Terms

  Process

  Special Considerations

  Companion Documents

  Evidence Table

  References

  Introduction

  Nursing documentation is essential for good clinical communication. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. 
  

  Aim

  To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistency across the RCH and improve clinical communication.
  

  Definition of Terms

  Documentation: encompasses all written and/or electronic entries reflecting all aspects of patient care communicated, planned recommended or given to that patient.
  
  ‘End of shift’ progress notes: nursing documentation written as a summary at the end or towards the end of shift.
  
  ‘Real time’ progress notes: nursing documentation written in a timely manner during the shift.
  
  ISBAR: (Identify, Situation, Background, Assessment, Recommendation) framework for clinical communication
  
  Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. 
  
  Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
  

  Process

  Nursing documentation will support the process;

  1. Patient assessment,
  2. Plan of care
  3. Real time progress notes

  Patient assessment

  An admission assessment is completed and documented on the Nursing Admission (MR850/A) as per Nursing assessment guideline.
  
  Exceptions: See Special Considerations
  
  At the commencement of each shift, following handover, patient introductions and safety checks, a ‘commencement of shift assessment’ is completed as outlined in the Nursing assessment guideline. These assessments are documented on the Patient Care Plan (MR 856/A). If there is more information gained from this assessment than space allowed, additional information is documented in the progress notes. In Neonates (Butterfly) and PICU (Rosella), commencement of shift assessments are completed in progress notes.
  

  Plan of Care

  Taking into consideration the patient assessment, clinical handover, previous patient documentation and verbal communication with the patient and family the plan of care for the shift is made and documented on the Patient Care Plan (MR 856/A). The plan should be negotiated with patients’ and their carers to ensure clear expectations of care, procedures, investigations and discharge, are set early in the shift. The plan of care should align with information on the patient journey board.

  Real time Progress Notes

  Documentation is captured in the patient’s progress notes in ‘real time’ throughout the shift instead of a single entry at the end of shift.
  
  Any relevant clinical information is entered in a timely manner such as;
  

  • Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor perfusion, hypotensive, febrile etc.
  • Change in condition, eg. Patient deterioration, improvements, neurological status, desaturation, etc.
  • Adverse findings or events, eg. IV painful, inflamed or leaking requiring removal, vomiting, rash, incontinence, fall, pressure injury; wound infection, drain losses, electrolyte imbalance, +/-fluid balance etc.
  • Change in plan (Any alterations or omissions from plan of care on patient care plan) eg. Rest in bed, increase fluids, fasting, any clinical investigations (bloods, xray), mobilisation status, medication changes, infusions etc.
  • Patient outcomes after interventions eg. Dressing changes, pain management, mobilisation, hygiene, overall improvements, responses to care etc.
  • Family centred care eg. Parent level of understanding, education outcomes, participation in care, child-family interactions, welfare issues, visiting arrangements etc.
  • Social issues eg. Accommodation, travel, financial, legal etc.

  Progress note entries should include nursing content and evidence of critical thinking. That is, they should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact and outcome for the particular patient and family involved.

  
  All entries should be accurate and relevant to the individual patient. Generic information such as ‘ongoing’ is not useful.
  Duplication should be avoided. Blanket statements about information recorded on other medical records are not useful, for example, ‘medications given as per Medication Administration Record (MAR). 
  Professional nursing language is used for all entries to clearly communicate assessment, plan and care provided. For example; ‘TLC’ does not reflect nursing care.
  Abbreviations should be consistent with RCH standards.

  Structure

  The structure of each progress note entry should follow the ISBAR philosophy with a focus on the four points of Assessment, Action, Response and Recommendation.
  
  Identify. Positive patient identification and ensure details are correct on documents. Write the current date, time and “Nursing” heading. The first entry you make each shift must include your full signature, printed name and designation. Subsequent entries on the same shift must be identified with date/time and ‘Nursing’ but may be signed only.
  
  Situation & Background. not often required for ‘real-time’ entries. Maybe relevant for admission notes or transfer from one dept to another.
  
  Assessment. What does the patient look like? What has happened? 
  
  Action. What have you done about it? Interventions, investigations, change in care or treatment required?
  
  Response. How has the patient responded? What has changed? Improvement or deterioration?
  
  Recommendation. What is your recommendation or plan for further interventions or care?
  
  Examples of real time progress note entries
  
  2/7/2014
  09:40 NURSING. Billie is describing increasing pain in left leg. Pain score increased. Paracetamol given, massaged area with some effect. Education given to Mum at the bedside on providing regular massage in conjunction with regular analgesia. Continue pain score with observations.
  10:15 NURSING. Episode of urinary incontinence. Billie quite embarrassed. Urine bottle placed at bedside.
  14:30 NURSING. Routine bloods for IV therapy taken, lab called- low Na+. Medical staff notified, maintenance fluids reduced to 5ml/hr. Repeat bloods in 6/24. Encourage oral fluids and diet, if tolerated, IV can be removed. 
  

  Special Considerations

  Critical care areas (Rosella & Butterfly).
  In these clinical areas, the ‘commencement of shift’ patient assessment and plan of care should be documented in the progress notes. Real-time progress notes are captured in either the clinical comments section of the observation charts or the in progress notes.
  Nursing Admissions are completed:

  • Neonates (Butterfly) – Neonatal Unit Nursing Admission/History, (MR 851/A)
  • Paediatric Intensive Care (Rosella) –PICU Management Plan, (MR 855/A)

  
  Emergency.
  The Emergency Department have department specific documentation tools, however progress notes should follow the structure as detailed above.
  
  Theatres.
  The Operating Suite uses ORMIS (Operating Room Management Information System) to record all surgical procedures
  http://www.rch.org.au/surgery/local_procedures/ORMIS_Nursing_Intra_Operative_Documentation/
  
  Banksia.
  The patient population in this unit requires assessment that is continuous throughout the shift and so commencement of shift assessment and plan of care are incorporated into progress notes.
  
  Nursing Admission - Day stay.
  May be used for patients staying less than 24hours in the areas of Day Medical Unit or Day of Surgery.
  
  Wallaby Ward.
  Commencement of shift assessments are completed verbally within two hours of the shift commencing by contacting families.

  • “How is your child?”
  • “Is there any change with your child since yesterday?”

  Verbal commencement of shift assessments along with ABCDF, risk, OH &S and medication assessments are documented on the Patient care plan (MR 856/A).
  
  All plans for care are documented on the Patient care plan and real-time progress notes should follow the structure as detailed above.
  
  Less than 24hr Admissions (Oximeters + Ambulatory Blood Pressure Monitoring) 
  Commencement of shift assessment and real-time progress notes are documented.
  Note: do not require Nursing Admission Forms.
  
  CVC Care
  Commencement of shift assessment, Patient care plan and real-time progress notes are documented.
  Note: do not require Nursing Admission Forms.
  

  Companion Documents

  • Documentation procedure
  • Patient Identification
  • Nursing assessment
  • Legislative compliance

  
  

  Evidence Table

  Complete evidence table document available at http://www.wch.org.au/nursing/governance
  

  References

  • Björvell, C., Thorell-Ekstrand, I., & Wredling, R. (2000). Development of an audit instrument for nursing care plans in the patient record. Quality In Health Care, 9(1), 6-13.
  • Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168
  • Cheevakasemsook, A., Chapman, Y., Francis, K., & Davies, C. (2006). The study of nursing documentation complexities. International Journal of Nursing Practice, 12, 366-374.
  • Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care, 22(4), 306-313.
  • De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R., & Matarese, M. (2010). ‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19, 1544-1552.
  • Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta‐study of the essentials of quality nursing documentation. International journal of nursing practice, 16(2), 112-124.
  • Johnson, M., Jefferies, D., & Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. Journal of nursing management, 18(7), 832-845.
  • Kargul, G. J., Wright, S. M., Knight, A. M., McNichol, M. T., & Riggio, J. M. (2013). The hybrid progress note: Semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency. American Journal of Medical Quality, 28(1), 25-32.
  • Newell, R., & Burnard, P. (2006). Vital notes for nurses: research for evidence-based practice. Oxford; Malden, MA Blackwell.

  
  

  Document Control

  Complete document control document available at http://www.wch.org.au/nursing/governance

  
  

   Please remember to read the disclaimer. 

  
  

  The development of this nursing guideline was coordinated by Sophie Linton, CNC, Nursing Innovation and Kylie Moon, CNC, Nursing Innovation, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2014.
• 
  
• Ref: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/nursing_documentation/  

Nursing Care Plan, Diagnosis, Interventions Hyperthermia, Fever, High Temperature

This nursing care plan and diagnosis with nursing interventions is for the following conditions: Hyperthermia, Fever, High Temperature

What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?

This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.

Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.

Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.

Nursing Care Plan for: Hyperthermia, Fever, High Temperature

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.

Scenario:

An 86 year old male comes into the ER. Pt is lethargic but alert enough to tell his health history and reason for coming to the ER. Pt states he has became very weak the past week and is unable to walk to his mailbox because he is so tired. The pt’s daughter is with him. According to the daughter,  the patient lives alone and his wife passed away 6 months ago. Vital signs: HR 100 regular, BP 135/78, Temperature 102.4 (orally), and O2 Saturation 95% on room air. Pt also informs you he hasn’t be able to keep any food or water down due to nausea. On assessment, you note that the patient looks dehydrated. Pt’s skin turgor is greater than 5 seconds. Lab results: WBC 19.3, UA (urinalysis) Leukocyte-esterase large and bacteria 5-10, WBC too many to count, Influenza screen negative.

Nursing Diagnosis:

Hyperthermia related to infection as evidence by temperature 102.4 orally, loss of appetite, weakness, and dehydration.

Subjective Data:

Pt states he has became very weak the past week and is unable to walk to his mailbox because he is so tired. According to the daughter,  the patient lives alone and his wife passed away 6 months ago. Pt also informs you he hasn’t be able to keep any food or water down due to nausea.

Objective Data:

Pt is lethargic but alert enough to tell his health history and reason for coming to the ER.  The pt’s daughter is with him.  Vital signs: HR 100 regular, BP 135/78, Temperature 102.4 (orally), and O2 Saturation 95% on room air.On assessment, you note that the patient looks dehydrated. Pt’s skin turgor is greater than 5 seconds. Lab results: WBC 19.3, UA (urinalysis) Leukocyte-esterase large and bacteria 5-10, WBC too many to count, Influenza screen negative.

Nursing Outcomes:

-Pt’s temperature will between 97.8-98.6 within 24 hours of hospitalization.-Pt’s skin turgor will be less than 5 seconds within 24 hours of hospitalization. -Pt will report increase in energy within 72 hours of hospitalization.

Nursing Interventions:

-The nurse will assess every four hours the patient’s oral temperature and report any temperatures greater than 100.4 to the doctor.-The nurse will administer ordered antipyretics to the patient for a temperature greater than 100.4 per md order. -The nurse will encourage and offer oral fluid intake every two hours to the patient. -The nurse will have the patient rate his energy level on a scale 1-10 with 10 being the highest in energy within 72 hours of hospitalization. Ref: https://www.registerednursern.com/nursing-care-plan-diagnosis-interventions-hyperthermia-fever-high-temperature/

Nursing Care Plan

If you aspire to become a nurse, you'll want to familiarize yourself with what Nursing Care Plans (NCPs) are all about. Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes. 

In essence, quality patient care that is consistent stems from a detailed NCP. What's more is a nursing care plan provides documentation of the care that was administered, something that is required by health insurance companies, and for patient health records.

A Closer Look at NCPs 

In most nursing workplaces, patient care is a team effort. Whether it’s one nurse taking over another’s shift, or a collaboration between different healthcare professionals, having a consistent care plan is what will ensure that everyone is on the same page.

A nursing care plan contains all of the relevant information about a patient’s diagnoses, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and a plan for evaluation. Over the course of the patient’s stay, the plan is updated with any changes and new information as it presents itself. 

Creating a care plan

Depending on the workplace, nursing care plans can vary. In most cases, however, you can expect that they will include the same pertinent information: the diagnoses, the anticipated outcome, nursing orders, and evaluation.

Diagnoses

According to the North American Nursing Diagnosis Organization-International (NANDA-I), nursing diagnoses compile a list of health problems or conditions that the patient is facing. This information is used to determine the appropriate care that the patient will receive. 

In order to make a diagnosis, a thorough patient assessment must take place. According to the American Nurses Association, that assessment should include physiological, psychological, sociocultural, spiritual, and economic data, as well as other lifestyle factors. 

In addition to just listing the diagnoses, a good care plan will also define them so there is no confusion moving forward. So for example, pneumonia is an excess fluid in the lungs.

Outcome/Goals

After a nurse performs a patient assessment and the diagnosis is made, the next step is to map out goals for the patient for both the short- and long-term. For instance, if a patient is diagnosed with acute pain from hypertension, the desired outcome might be that the patient begins a new prescription and the pain becomes is controlled.

Nursing Orders/Interventions

This is the part of the nursing care plan where all the action is. Based on the diagnosis and the desired outcome, here, nurses will have a checklist of how to care for the patient. It might include things like checking vital signs every few hours, assess patient by asking pain scale questions, provide medication, etc. Expect to include a lot of specifics here, including times, dosages, etc.

This part of the nursing care plan will be adjusted accordingly as the patient’s condition improves or changes in any way. All care is carefully documented in the patient’s health record and will be used to determine if the patient can be discharged.

Evaluation

Throughout the patient’s stay, their status will be monitored and evaluated so that the plan can be updated as necessary.  As progress is made toward the patient goal, the evaluation is used to determine if the nursing orders need to change, or are complete.

Putting NCPs into Practice

Learning how to create a nursing care plan is something you will learn a lot about in nursing school, and then later, on the job as a Registered Nurse. The good news is that you are not on your own.

There are many online resources that provide templates, sample care plans, and even video tutorials to help you learn the ropes of NCPs. There’s even an app from NANDA that gives you access to over 300 common care plans. 

You can also search for NCPs by your specific nursing specialization, for example, such as if you work in medical-surgical or pediatrics. Even Pinterest has a collection of nursing care plans to peruse.

Learning how to write up a nursing care plans is a vital part of your responsibilities as an RN. The key is to be detailed and accurate and to use the resources that are available to help you.

Reference: https://nurse.org/articles/what-are-nursing-care-plans/