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. 



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!

Why Nurses Become Travel Nurses

Why Nurses Become Travel Nurses

Why Nurses Become Travel Nurses

These days many nurses are leaving bedside nursing to pursue travel nursing. With the many perks and benefits of travel nursing, we can’t blame them too. Travel nursing allows nurses to explore and experience diverse practices and new environments.

It is also a great way to connect and work with nurses in different nursing communities. With great pay, free housing, and many more, it is no wonder nurses are packing up their bags to become travel nurses. 

As a travel nurse, you can work in all 50 states as your assignments vary and can be as long as 13 weeks. You also have the liberty to choose which assignment works for you based on many factors. These factors include:

  • Climate
  • Nursing opportunities
  • Payment and incentives
  • Location
  • Proximity to friends and family
  • Activities to do
  • Compensation

Besides having this option, there are also many pros to travel nursing, which makes it more favorable. Among these include:

  • There are fewer nursing responsibilities.
  • Many assignments have higher pay.
  • You have free housing or housing options with bigger discounts.
  • There is flexibility to work as much or as little as you want.
  • You get to explore different work cultures.
  • All your travel expenses are reimbursed when moving from one contract to another. 
  • You get to explore different places. 
  • There are work bonuses. 

So Many Reasons Why

Another good reason why many nurses pack up and leave the bedside is stress. There are many reasons why nurses are stressed at work. It could be due to nursing shortages, unfair nurse-to-patient ratios, workplace politics, and exhaustion. If you are a nurse yearning for better pay and a less stressful environment, this could be a great opportunity to grab. 

The idea of working in a different place is also awesome. You get to explore new places, and if you’re the adventurous type, you can explore so many places as a travel nurse. Activities like hiking, camping, trekking, and even going to the beach are only among the recreation you can do as a travel nurse. Depending on where you are assigned, adventure awaits many travel nurses! 

You can also choose the nursing specialty or unit you want to work as a travel nurse. There are many special areas that you can apply to. If you have experience as an ICU nurse, you can look for assignments that allow travel nurses to work in ICU. The same goes for those with experience in PICU, ER, and many others. 

It is no secret that many travel nurses are paid more than staff nurses. Most of your travel nurse salary is tax-free simply because you travel more than 50 miles from home. However, hourly wages are usually non-negotiable. But you will be given bonuses and benefits as it fits. 


We can’t blame nurses who are packing up to become travel nurses. Many reasons may affect their decisions too. Whether for their clinical experience, money, or adventure, it is a good way for nurses to get some weight off their backs and see the world.

Travel nursing offers adventures, reliable income, and flexibility; as a nurse, this sounds like the freedom you’d want to get your hands on. 

Looking for more nursing and travel nursing information? 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. 



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!

5 Qualities of a Good Nurse Leader

5 Qualities of a Good Nurse Leader

5 Qualities of a Good Nurse Leader

So you have the qualities of a good nurse leader? Leadership is a vital foundation for its success. Great leaders are also great managers and are an inspiration to their colleagues. But what are the qualities of a good leader, especially in the nursing field?

We need to improve the quality of care in our healthcare system. It is why there is a call for effective leadership among nurses to help improve individual patient care in the general health sector. 

According to ANA or the American Nurses Association, an excellent nurse leader is passionate about excelling in the healthcare sector by applying nursing leadership skills and principles.

A good nurse leader must focus on the quality of care, safety, and team management among nurse managers and resident nurses. 

Nurse leaders also advocate for their profession and patients while ensuring a positive and professional work environment. But what are the qualities of a good nurse leader? 


Must-have Nurse Qualities

Effective nursing leadership is crucial for nurses who want to advance their careers. Being a leader means focusing on skills that will help them grow. But are these skills? And how can they help you become an excellent nurse leader?

Here’s what you need to know:


1. Excellent and effective communication skills

A good nurse leader must communicate effectively with fellow nurses and patients. When communication is effective, it encourages collaboration among members of all levels and positions within the healthcare sector.

To be an effective communicator, a good nurse leader involves active listening and providing feedback to nurses, especially those in training. 


2. Precise decision-making skills

The nursing field involves situations where decisions are made daily, whether small or big. Junior and resident nurses look up to their nurse leaders for these decisions and seek their advice.

It is why an excellent nurse leader has efficient, effective, and precise decision-making skills to help organize and provide direction to their healthcare team. 


3. Can resolve conflicts

Conflicts cannot be avoided. Every work sector has them, and yes, even in healthcare organizations. Conflict resolution is an essential nursing leadership skill. It allows nurse leaders to improve teamwork and resolve issues within the healthcare sector.

They also help in productivity and patient satisfaction. When conflicts are resolved, developing care plans and diagnoses for patients are easy, even when healthcare team members have different opinions. 


4. Gives guidance

Interpersonal and motivational strategies make individual and group trainee nurses effective under nurse leaders. Through their mentorship, nurse leaders cultivate continuous learning and development within the healthcare system.

An effective nurse leader also sets the standards for new and younger nurses, who can one day grow to become nurse leaders.


5. Adaptability 

The nursing field is ever-changing. A good nurse leader must be able to adapt and evolve to the constant changes within the healthcare industry; every nurse leader has to face the uncertainty of their daily situations.

They must also communicate these changes effectively to their subordinates so they can come up with solutions to these changes. 


Looking for more nursing and travel nursing information? Check out these helpful links!