Nursing Care Plan: What You Need to Know

Nursing Care Plan: What You Need to Know

Nursing Care Plan: What You Need to Know

A nursing care plan is essential to student nurses and nurses alike. It is the basis of patient care and helps understand the patient’s condition. How can you write an effective nursing care plan? 

 

What is a Nursing Care Plan?

A nursing care plan is a plan that contains relevant information about the patient’s diagnosis, goals of the treatment, and specific nursing orders. It also contains the evaluation plan and actions that must be performed on the patient. 

The nursing care plan is also updated throughout the patient’s stay—any changes in the patient or if there’s new information added to the plan. In some hospitals, nurses must update their care plan during and after the shift to see improvements. 

 

The Purpose

The nursing care plan aims to help define a specific patient’s nursing guidelines and treatment. It is a plan that helps guide nurses throughout their shift in caring for their patients. It also allows nurses to give their patients focused and attentive care. 

 

What Makes up a Nursing Care Plan?

There are several components used in a care plan. These include the following:

  • Nursing Diagnosis – this is a clinical judgment that helps nurses develop a care plan for their patients.
  • Expected outcome – is a measurable action plan for a patient to achieve within a specific time frame. 
  • Nursing interventions and rationales – are actions to be taken to achieve the expected outcomes and reasons behind them. 
  • Evaluation – is how you determine the effectiveness of the care plan and see if the expected outcomes are met within the said time frame. 

These components are essential to the overall nursing care plan and process. A good nursing care plan must have these sections, or it will not make sense:

 

4 Types of Nursing Care Plans

There are many ways to write a care plan. Memorizing how they help you is essential. Here are the four types:

  • Informal – is a care plan that exists in the nurse’s mind. The action plan for this care plan is what the nurse wishes to accomplish during their shift. 
  • Formal – a type of care plan that is written or computerized. It is organized and coordinates with the patient’s care information and plan.
  • Standardized – is nursing care for a group of patients with the same everyday needs. 
  • Individualized – is a care plan tailored to a specific patient’s needs. 

 

How to Write a Nursing Care Plan

One of the first things you need to determine before writing a nursing care plan is to see the problems affecting the patient. What are the medical problems that affect them? Not just the medical problems but the psychosocial problems as well. 

Once you have listed the problems affecting the patient and the corresponding nursing diagnosis, you can determine the essential ones. Consider the ABCs or the Airway, Breathing, and Circulation to determine this. However, these will not always be the basis or be relevant to your patients. 

 

Step 1 – Assessment

To determine your care plan, always assess your patients first. It means you must gather subjective and objective data from your patients. 

Subjective data is what the patient has verbalized. It could be symptoms, feelings, perceptions, and even their concerns. 

Objective data is the information you’ve gathered based on observation. These are often measurable and can come from:

  • Vital signs – blood pressure, respiratory rate, heart rate
  • Verbal statements of the patients and their family
  • Physical complaints – for example, headache, pain, nausea, vomiting
  • Body conditions – assessing the patient from head to toe
  • Medical history
  • Height and weight
  • Intake and output
  • Patient feelings, concerns, perceptions
  • Laboratory data
  • Diagnostic testing – like X-ray, EKG, echocardiogram etc.

 

Step 2 – Diagnosis

A nursing diagnosis best fits the patient’s condition, objectives, and goals for the individual’s hospitalization.

The North American Nursing Diagnosis Association or NANDA, “a nursing diagnosis is a clinical judgment about the human response to health conditions, life processes, or a vulnerability for that response by an individual, family, group, or community.” 

Nurses can also formulate a diagnosis based on Maslow’s Hierarchy of Needs. With this, nurses can formulate a treatment plan and prioritize them. It also helps determine their next step. 

 

Types of Nursing Diagnosis

There are four types of nursing diagnoses that you can do. These are:

  • Problem-focused – the diagnosis is based on the problem present in the patient. 
  • Risk – includes the risk factors nurses see that require intervention from them and the healthcare team before a real problem develops.
  • Health promotion – aims to improve the general well-being of the patient, their families, and/or community. 
  • Syndrome – occurs in a pattern or can be addressed through the same nursing interventions. 

Once the nurses determine the diagnoses, they can begin their nursing diagnosis statement. There are three main components of a nursing diagnosis. These are:

  • Problem and its definition – refers to the patient’s current health problem and the nursing interventions needed.
  • Risk Factors or etiology – are the possible reasons behind the problem or the contributing factors that led to the patient’s condition. 
  • Defining characteristics – are the signs and symptoms that allow the specific diagnostic label in the place of defining characteristics for risk nursing diagnosis. 

 

Step 3 – Outcomes and Planning

Once you have your nursing diagnosis, create a SMART goal based on evidence-based practices. SMART goals are:

  • Specific
  • Measurable
  • Achievable
  • Relevant
  • Time-bound

It is also best to consider the medical diagnosis of the patient and overall condition for your data collection. Consider the goals you want to achieve for this patient and the short- or long-term outcome. It should be realistic and something the patient wants to do. 

 

Step 4 – Implementation

After setting all the goals, implement them to help your patient achieve them. Some actions will have immediate results; others may be seen later during hospitalization. During the implementation phase, you will be performing your nursing care plan. 

Your care plan must include the patient’s family, behavioral and physiological aspects, community, safety, health system interventions, and complex physiology. 

Some interventions implemented are diagnosis or patient-specific, but several can be completed within a shift. These are:

  • Pain assessment
  • Position changes
  • Fall prevention
  • Providing cluster care
  • Infection control

 

Step 5 – Evaluation 

The last part of your nursing care plan is the evaluation phase. It is where you evaluate the outcome of your care plan and see if the goals are met during the shift. The possible outcomes are met, ongoing, or not met. 

The evaluation can determine if the goals and interventions need improvement. Ideally, these goals must be met by the time of discharge.

However, it is not always the case, especially if the patient is discharged to home care, hospice, or long-term care facility. The outcome of your goals always depends on the patient’s condition. 

It would be best to choose achievable nursing goals that the patient can do. It will also help the patient feel that they have accomplished something and are progressing toward recovery. 

 

Takeaway

Nursing care plans are essential in patient care. They are your guidelines for your patient’s progress. You must learn to write one and implement your care plan each shift. It will help you polish your nursing skills as you learn how to care for your patient.

Hopefully, this post helped you; good luck!

 

Looking for more student resources? Check out these helpful links!

7 Effective Study Tips for Student Nurses

7 Effective Study Tips for Student Nurses

7 Effective Study Tips for Student Nurses

There are many strategies and study tips for student nurses. But only a few are as effective. You must know what works for you and stay on it. Studying can sometimes become overwhelming, and you can relate to this situation if you’re a student nurse.

We’ve been to nursing school too, and we know that student nurses have a lot on their plate, not to mention working for their clinicals. And there are moments when everything feels like it’s all happening simultaneously! 

 

How to Study More Efficiently: Tips for Student Nurses

Yes, it is exhausting and overwhelming, but it doesn’t have to be the case. Knowing how to manage your studies and figure out a way that works for you is possible.

In this post, we will share the most effective study tips so you don’t feel as overwhelmed with everything in nursing school. Read on for more. 

 

Know your learning style 

One of the first things you must realize is your learning style. Some students learn well by reading; some write them down, while others learn faster with visual aids or listening.

Some students may even learn better through demonstration. Whatever your learning style is, always work with the ones that are most effective for you. There’s no right or wrong way of learning.

If you need to know what works best for you, try them all and see which ones help you retain more information. 

 

Scheduled study time

Your time as a student nurse feels short, especially when you’re busy with other activities. Sometimes, it takes a lot of work to find time to actually study. Setting a schedule for study time is the best way to do it.

It will help you determine which topic needs priority and see those that need extra study time. It will also help you catch up with your assignments, make nursing care plans, and read topics you’re having difficulty with. 

 

Have a break

Take a break whenever you can. Yes, you have many things to study and do; taking a break is okay too. When things get too overwhelming, remove yourself from the situation and breathe.

Your study notes and books will still be there when you return. Take a time out and do something refreshing for your mind and memory. You cannot push yourself to do so many things all at once.

Take a walk or have ice cream. Meditate. Get your favorite coffee. Do whatever makes your mind at ease and clear the rumblings of your thoughts. Once you feel better, you can return and tackle your nursing notes again! 

 

Avoid cramming for your exams

Cramming for your exams is not a good idea. That is why you must have a good study schedule. You can divide your study notes and give a time allotted. It will help you see which topics need more reviewing and which need little time to study.

This strategy will help you, especially when exams are coming up. Knowing that you have studied all your lessons help lessen your anxieties and avoid cramming.

 

Rewarding yourself

Remember to reward yourself. After a long week or weeks of studying, you must reward yourself for all your hard work. Nursing school is not a joke; those who persevere are the ones who make it.

But no one perseveres without giving themselves a break too. However you want to reward yourself, it’s up to you. Whether it be going on a spa day, out with friends, or simply binging on your favorite TV series, do it!

All study and no play make one an exhausted student nurse. 

 

The 45-15 Study Strategy

Are you familiar with the 45-15 study strategy? This type of strategy is all about combining your study time and breaks. To do this, you need to set your timer for 45 minutes of studying and 15 minutes break.

It is helpful for people who cannot concentrate well. The key is to truly focus your attention on your studies within the given 45 minutes and enjoy your 15-minute break afterward.

This strategy is one way to prepare your brain to concentrate. Of course, you can always try other study strategies that work best for you. 

 

Study Groups work

Study groups are the best. But make sure that the purpose of this group is to REALLY study. If you and your groupmates will only goof around while studying, then what’s the point? Study groups work because you can divide the topics among each member.

Learning as a group is better because everyone has input to share. You can create mini quizzes, recitations, and presentations when discussing a topic. It’s an effective way to absorb hard-to-understand topics and enjoy how each member presents the subject.

It will help you retain more information too. 

 

Your Takeaway

Nursing school is not easy, but there are many ways to help you rise above the exams and school activities. It’s a matter of time management and knowing your priorities. Hopefully, these tips for student nurses will help.

Nursing school is challenging, but you can do so with discipline, focus, and perseverance. Enjoy each moment and keep your eyes on the price; you will be a future nurse and, maybe, one of the best! Good luck!

 

Looking for more student resources? Check out these helpful links!

4 Main Roles of a Student Nurse

4 Main Roles of a Student Nurse

4 Main Roles of a Student Nurse

The roles of a student nurse may be limited but essential at the same time. Many student nurses help in many clinical areas. They help promote, maintain, and restore patients’ health after a procedure to gain practical experience. They must follow the clinical instructor’s instructions to execute these duties properly.

Being a student nurse offers you to practice what you’ve learned in nursing school. It may be challenging but all worth it. 

 

Main Roles of a Student Nurse

According to the Bureau of Labor Statistics, about 3 million registered nurses are employed in hospitals, nursing homes, long-term facilities, clinics, and other nurse-related work environments.

As a student nurse, your role is not limited to your campus alone but also in a hospital setting where you will be caring for patients too. And as you help your patients to heal, you are also tasked to promote their privacy, dignity, and safety. 

 

Get your patient assignment

Before you start your nursing clinical rounds, your clinical instructor will assign your patient assignment. This assignment has your patient’s name that you’ll be assigned for the day.

Your clinical instructor will also expect you to understand your patient’s diagnosis. You must know about their medical condition and the treatment they need. 

 

Nursing care

As a student nurse, you’ll be responsible for assisting your patients whenever they need help, particularly when eating or bathing. You will also help in keeping your patients warm after their baths. Also, when bathing your patients, you must always keep their beds dry.

Placing a towel under your patient does the trick. Always ask for consent when caring for your patients because some of them are uncomfortable when there are student nurses around. 

 

Administer medications

Part of your clinical rotations as a student nurse is to give or administer medications after determining the effects of the medication on them. Of course, this will only be done with the supervision and approval of your clinical instructor. 

To prepare, ensure you have the right dose and administer the medication at the right time. As you do this, call the patient by name as you administer the meds. Another way to confirm their identity is by checking their patient ID. 

 

Charting 

One of the most common sayings used in the medical field is, “If you didn’t chart it, it never happened.” It is why you must provide all the information or procedure you did to your patient in their chart. It will serve many purposes in terms of caring for your patients. 

Charting means you must document all the medical procedures done. It includes your patient’s condition, medication list, treatment plan, and symptoms experienced by your patients. A patient’s chart also includes the patient’s medical history and diagnosis provided by the physician. 

 

Always Know the Roles of a Student Nurse

Your clinicals are the best time to gather nursing experience. It is also an excellent time to get a hands-on experience with many nursing procedures and observe how a nursing unit works. Knowing your main roles as a student nurse will make your nursing clinicals easier. 

Of course, it will be a little intimidating to be surrounded by professional and seasoned nurses already equipped with skills and knowledge regarding patient care. But with careful planning and guidance from your clinical instructor, you will also be an excellent student nurse. 

 

Looking for more student resources? Check out these helpful links!

4 Tips to Do the Night Before Your NCLEX Exams

4 Tips to Do the Night Before Your NCLEX Exams

4 Tips for the Night Before Your NCLEX Exam

Your NCLEX exam is scheduled for tomorrow; what should you do? Here are four tips to do the night before your NCLEX exam. 

 

Helpful Tips to Remember the Night Before Your NCLEX Exam

Congratulations! You are 1 test away from becoming a registered nurse. Before you take the examination tomorrow, remember these tips and apply them where you see fit.

What should you do on the night before your NCLEX exams? Here are helpful reminders:

 

Be as ready as you can

Cramming at the last minute is not the way to go. At this point you know everything you can. . You can skim over your notes but trying to learn any new concepts won’t help. 

Remember, you already studied for the exam, so be confident that you can answer the exam questions to the best of your abilities. 

Instead of cramming, get enough sleep. You can also review your test instructions, ensure that you have all the documents you need for the examination, and make sure you know how to get to the testing center. You are ready for tomorrow. 

Be sure to set the alarm clock a few hours before the exam. Check your car’s gas and if you have enough to drive yourself to the testing center. 

Remember that cramming the night before will only make you anxious. Instead, try to relax and go to sleep early.

 

Remind yourself that it is normal to be tense

If you are overthinking, STOP. You will only get yourself worked up, which will trigger your anxiety. 

What you can do is practice breathing. If you feel anxious about tomorrow’s exam, pause, take a deep breath in, and exhale. 

Remind yourself that it is common to feel the jitters the night before the NCLEX exam. After all, this is an important test to take. The tension you feel right now is normal. 

Try to relax; take a nice hot bath, and light up some scented candles or diffuse oils. Stressing about the exam tomorrow will not help. You might as well enjoy this time. 

 

Treat yourself; you deserve it!

The night before you take the exam, eat a good meal. Consider it as your reward. You have been preparing for this moment for many months. Treating yourself to a night dinner is the reward you deserve for all your hard work. 

If you don’t want to eat dinner, get something you have been depriving yourself of for months. Whatever treat you give yourself, reflect on your efforts to get this far. 

NCLEX is not an easy exam; treating yourself is one way to boost your self-confidence and encourage you to do well on your exam tomorrow!

 

Get plenty of sleep

Once you have eaten, prepared your documents, taken a nice shower, and prepared your clothes for tomorrow, you can go to bed. Say your prayers (if you’re religious of course) and go to sleep early.

Don’t stay up late. It will mess with your body’s clock. You might also wake up late tomorrow, so avoid this. If sleeping early means you must miss your favorite show or not reply to messages for a while, so be it! 

 

In Closing

Preparing the night before your NCLEX exam is essential. You must not overlook it and be complacent. If you are ready to answer the questions, be prepared physically, mentally, and emotionally. 

The opportunity to pass NCLEX on your first try is a blessing. You should also be ready for it as much as possible. I hope these tips helped you prepare for the exam, good luck!

 

Looking for more student resources? Check out these helpful links!

3 Tips to Make Your Nursing School Clinicals Enjoyable

3 Tips to Make Your Nursing School Clinicals Enjoyable

3 Tips to Make Your Nursing School Clinicals Enjoyable

Your nursing school clinicals are one of the most important parts of nursing school. It is a time to learn about patient care, know what nursing style you like, and find the right nursing path you would like to pursue.

It is also the best time to hone your nursing skills and develop self-confidence as a future nurse. While this is an exciting time, it can also be nerve-racking. But before you get all nervous, here are helpful tips you can follow.

 

Enjoy your nursing school clinicals with these tips

A clinical rotation can last about a week. It’s relatively short, so you must make the most of your time. To experience the best clinical, you must be prepared, energized, and curious. 

 

1. Get ready and prepare yourself

Going into your nursing clinical means, you’ll be in shifts. For the clinical round, make sure to come on time. Go to bed early the night before your clinical and set your alarm for the next day.

Come on time and have your questions ready based on your lectures or readings. Bring your questions to the pre or post-conference. Asking questions will help you prepare for your NCLEX exams or nursing board exams. 

 

2. Stay energized at all times

Nursing school is stressful as it is, and it may be challenging to feel energized all the time. But understand this; your clinical may also add more to the pressure of studying and meeting class deadlines.

On the bright side, however, nursing school clinical will teach you much about what it takes to be a real nurse. It will also enhance your skills and build your confidence as a future member of the healthcare team. 

Always have a heart breakfast to keep your energy up for your shifts. Have a diet rich in carbs and protein; you’ll need it throughout the day. Of course, you will be given breaks by your clinical instructors too.

Bring healthy and energizing snacks that will help boost your energy. Avoid drinking stimulants like coffee or energy drinks. It will wear you out once caffeine crashes. Bring your water bottle and keep yourself hydrated at all times too.

It’s the best way to combat sleepiness and that tired feeling. 

 

3. Stay curious 

During your nursing school clinicals, you will be working with patients for the first time and will learn what it’s like to do patient care. It’s also an excellent opportunity to see how seasoned nurses care for their patients and observe what they do in the unit. And once you have an assigned patient, research all about the medications given to them and their diagnosis. 

Understand that your clinical experience is more than just reading your patient’s chart and taking vital signs. It’s all about understanding how the nursing team works and knowing that you will be a part of that culture in the future. 

Clinicals are fun, but you must also be serious about it. It’s a learning opportunity too. Take it as your “warm-up” to your real nursing career in the future, so enjoy it! Being nervous about your clinical is expected, so be prepared for it. Hopefully, these tips help!

Looking for more student resources? Check out these helpful links!

Preparing for the NCLEX Exams: 6 Proven Tips for Passing

Preparing for the NCLEX Exams: 6 Proven Tips for Passing

Preparing for the NCLEX Exams: 6 Proven Tips for Passing 

Preparing for the NCLEX exams is one of the most important things that any nursing student should prepare for. But the question in many nursing students’ minds is, how do you prepare for the NCLEX? If you are asking the same question, let these tips help you prepare for this upcoming exam. 

Passing the NCLEX exams is like hitting gold. It is your ticket to a better and brighter future. Before taking the exam, here are some excellent tips you can apply to your study plan.

 

1. Understand the NCLEX Format.

When you understand how the NCLEX format works, passing it will be easier. NCLEX uses the CAT format or computerized adaptive testing format. It means that not a single exam is identical.

The algorithm produces a new set of questions based on your performance on the previous test questions. Keep in mind that the test bank is comprehensive and contains all kinds of question styles and topics of content. 

The exams will produce around 60 questions minimum plus 15 pre-questions with 145 maximum questions. The candidate can pass the test when the tester has answered enough questions with correct answers at about the 95% confidence interval. Candidates will fail if they cannot maintain or rise above 95% confidence. 

It means that to pass the NCLEX, you must get above the passing line that shows competency with marginal doubt. The test can end at any point when the computer has determined your performance.

You are given a maximum time allowance of 6 hours to do this. So, all you have to do is pass the 60-145 questions. 

 

2. Avoid self-criticism.

The questions tend to get harder as you move forward. Don’t get frustrated when you get a few wrongs in a row, and don’t automatically assume you’ve failed. The best thing you can do is stay focused on your questions.

Remember, the NCLEX exam determines your knowledge and tests your endurance. It is best to keep answering instead of talking yourself down each time you get a wrong answer. 

 

3. Manage your stress.

It is expected to get worked up before the examination, but it is recommended that you find a way to manage your stress. Some test-takers get anxious before taking the NCLEX, and if you are one of them, don’t worry; there are plenty of ways to deal with test stress. 

One of the first things you should do is take as much time as you can to prepare for the NCLEX but don’t make studying your entire life. There is always time for everything, and balancing your studies with hobbies is a must. 

Be sure to include time for exercising, eating well, and going out. Keeping a balanced life during studying and doing what you love helps ease your mind from any anxiety you might feel before the exam. Some nurses say there is a rule not to study the day before the exam, only a quick skim through some notes.

On the day of the exam, do not study. Do not attempt to take a glance at your notes or review anything. It will only make you more anxious. Instead, you need to relax, do a short meditation, and eat breakfast before going to the exam center. In short, do something that will keep you grounded and calm. 

The best thing you can do is to study appropriately beforehand. When you know that you have covered everything during your study days and are confident that you will pass, taking the NCLEX exam isn’t that scary. 

 

4. Make a study plan.

Making a study plan means you need to create time for studying. Create a schedule for the week and set aside the hours you need to study. Be sure to include a goal each time you are studying too. It could be as simple as answering 4 25 question practice exams or reading a few chapters on the topic you are tackling. 

Keep in mind that you are wasting time when you do not have any goals when studying. The NCLEX is not about how long you have studied or how many hours you have put in. It is about how much you understand the context of each nursing topic. Make use of your time wisely. 

 

A. Not all past clinical experiences can help. 

I have bad news for those who worked as a nurse aid, tech, or even nursing students who volunteered. Your clinical experience cannot help you when you take the NCLEX exams. Why do you ask? 

The NCLEX exam is based on tested, researched, and evidence-based practices that you may not have learned in your clinical experience. Facilities will have different guidelines and protocols that are just as safe or as effective, BUT never assume that they are the same regarding the NCLEX. 

It is best if you answer the exam questions as if you did not have any real-life experience as a nurse. 

 

B. Practice your test-taking skills. 

Make use of test-taking strategies so you can eliminate the wrong answers. It will also help you with solutions like ALL THAT APPLY or NONE APPLY. Always remember to put patient safety first before considering other options. With continuous practice, you will see themes in the answers. For example:

  • Be sure to assess the patient first; calling a doctor is not always the best answer. 
  • Remember your ABCs – Airway, Breathing, Circulation. 
  • Deductive reasoning can also help you even if you don’t know the topic. 
  • If you have no exact answer, follow your gut. A nurse’s intuition can help you out. 

As you practice your test-taking skills, you will realize there will always be “select all that apply” questions. But if you use a systematic approach and tackle the wrong answers first, you have a higher chance to answer each question correctly. 

 

5. Do more than just answer the practice tests.

Completing practice exams is good, but you can also go beyond that. After answering the practice questions, you can read about the answers and why they were right or wrong.

Write down the concept you would like to tackle on your next study time so you are always prepared for the next day.  Take as much time as you think you need to devote to various study methods; they each have their benefit and will pay off in the long run.

 

6. Prepare for the NCLEX Exam day. 

The night before you take the exams, go to bed early, or better yet, ensure you have enough sleep throughout the week before the NCLEX. Hide your notes and try not to study. Be sure to put gas in your car, set your alarm for the next day, shower, and arrive early at the testing center. 

Bring snacks for your breaks during the test, and stay hydrated. If you get cold fast, bring an extra layer of clothing or a hoodie if allowed. In short, be as prepared as you can be.

Not only will it show that you are serious about your exams, but it also shows your character as a person and perhaps as a future nurse. 

 

Believing in Yourself is the Key

Preparing for the NCLEX exams is not that hard. All you have to do is stay focused. You are already on your way to becoming one of the best nurses. You had proven this when you passed the nursing school.

So believe that you can pass the NCLEX, and you will! NCLEX is the last step toward your career as a professional nurse. Hopefully, you find these tips helpful as you prepare for the exams; best of luck!

 

Looking for more student resources? Check out these helpful links!