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Registered Nurse
15-20 minutes

Notes on Nursing Care Plans (NCP)

The Nursing Care Plan (NCP) Notes template by s10.ai is a vital resource for nurses to meticulously document patient care plans. This template is crafted to record in-depth assessment data, nursing diagnoses, associated factors, and defining characteristics. It also delineates overarching goals, anticipated outcomes, and precise nursing interventions with justifications. Nurses can leverage this template to assess patient progress and adjust the care plan as needed. Perfect for diverse healthcare environments, this template guarantees a systematic approach to patient care, enhancing communication and continuity of care among healthcare professionals.

2,934 uses
4.5/5.0
J
Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

Clinically Significant Assessment Data:
- [describe cluster of assessment data for Nursing Diagnosis 1] (include all pertinent assessment findings, such as respiratory status, symptoms, vital signs, diagnostic test results, history, and other relevant observations related to the primary nursing diagnosis.)
- [describe cluster of assessment data for Nursing Diagnosis 2] (include all pertinent assessment findings related to the second nursing diagnosis, such as psychological symptoms, behavioral observations, physiological responses, and contributing factors.)
Nursing Diagnosis 1:
- The actual problem: [state the primary nursing diagnosis and corresponding NANDA code] (ensure the diagnosis accurately reflects the patient’s current condition based on the assessment data.)
Related Factors:
- [list factors contributing to the nursing diagnosis] (include physiological, environmental, or behavioral factors that have led to the problem, ensuring alignment with patient history and assessment findings.)
Defining Characteristics:
- [list key signs and symptoms that support the nursing diagnosis] (include measurable clinical indicators such as vital signs, physical examination findings, patient-reported symptoms, and diagnostic test results.)
Overall Goal:
- [state the overall goal for this nursing diagnosis] (formulate a broad, patient-centered goal that reflects the desired improvement in health status.)
Expected Outcomes:
- [list specific, measurable, and time-bound expected outcomes] (ensure each outcome is realistic, includes a timeframe, and describes how improvement will be assessed.)
Nursing Interventions:
- [list specific nursing interventions that will address the nursing diagnosis] (include direct patient care activities such as administration of treatments, patient education, positioning, and monitoring.)
Rationale:
- [provide a rationale for each nursing intervention] (justify the intervention using evidence-based practice, referencing clinical guidelines or research findings where applicable.)
Evaluation:
- [assess whether the goal was met, partially met, or not met] (use objective measures such as symptom improvement, vital sign stabilization, and patient-reported outcomes to determine effectiveness.)
Revision (if goal was not met):
- [describe necessary modifications to the care plan] (include additional interventions, referrals, or changes to treatment strategies based on patient response.)
Nursing Diagnosis 2:
- The actual problem: [state the secondary nursing diagnosis and corresponding NANDA code] (ensure the diagnosis aligns with patient-reported concerns and observed clinical findings.)
Related Factors:
- [list factors contributing to the secondary nursing diagnosis] (include psychological, physiological, and situational factors relevant to the condition.)
Defining Characteristics:
- [list key signs and symptoms that support the secondary nursing diagnosis] (include objective and subjective indicators such as reported feelings, physiological measurements, and observed behaviors.)
Overall Goal:
- [state the overall goal for this nursing diagnosis] (ensure it addresses the primary concern and reflects a desired improvement in patient well-being.)
Expected Outcomes:
- [list specific, measurable, and time-bound expected outcomes] (ensure they align with the goal and include clear indicators of success.)
Nursing Interventions:
- [list specific nursing interventions for the secondary nursing diagnosis] (include actions related to patient education, emotional support, symptom management, and therapeutic techniques.)
Rationale:
- [provide a rationale for each intervention] (explain how the intervention is expected to address the issue and improve patient outcomes.)
Evaluation:
- [assess whether the goal was met, partially met, or not met] (document progress using objective and subjective measures.)
Revision (if goal was not met):
- [describe necessary modifications to the care plan] (include alternative strategies, potential referrals, and additional interventions if needed.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

Clinically Relevant Assessment Data:  
- Nursing Diagnosis 1: Patient exhibits impaired gas exchange, NANDA code 00030. Assessment findings include a respiratory rate of 28 breaths per minute, oxygen saturation at 88% on room air, and bilateral crackles upon auscultation. History of chronic obstructive pulmonary disease (COPD) exacerbation noted.  
- Nursing Diagnosis 2: Patient shows signs of anxiety, NANDA code 00146. Psychological symptoms include restlessness and reported feelings of unease. Behavioral observations show frequent pacing and difficulty concentrating.  
Nursing Diagnosis 1:  
- The actual problem: Impaired gas exchange, NANDA code 00030.  
Related Factors:  
- Chronic obstructive pulmonary disease (COPD), smoking history, and environmental exposure to pollutants.  
Defining Characteristics:  
- Increased respiratory rate, decreased oxygen saturation, and abnormal lung sounds.  
Overall Goal:  
- Enhance oxygenation and respiratory function.  
Expected Outcomes:  
- Oxygen saturation will rise to 92% or higher within 48 hours.  
- Respiratory rate will decrease to 20 breaths per minute within 24 hours.  
Nursing Interventions:  
- Administer supplemental oxygen as prescribed.  
- Position patient in high Fowler's position to facilitate lung expansion.  
- Educate patient on pursed-lip breathing techniques.  
Rationale:  
- Supplemental oxygen increases oxygen availability.  
- High Fowler's position optimizes lung mechanics.  
- Pursed-lip breathing helps improve ventilation and reduce dyspnea.  
Evaluation:  
- Goal partially met; oxygen saturation improved to 90%, but respiratory rate remains elevated.  
Revision (if goal was not met):  
- Increase frequency of respiratory therapy sessions and consider bronchodilator therapy.  
Nursing Diagnosis 2:  
- The actual problem: Anxiety, NANDA code 00146.  
Related Factors:  
- Hospitalization, unfamiliar environment, and health status uncertainty.  
Defining Characteristics:  
- Restlessness, pacing, and difficulty concentrating.  
Overall Goal:  
- Alleviate anxiety levels and enhance coping mechanisms.  
Expected Outcomes:  
- Patient will report a decrease in anxiety levels within 24 hours.  
- Patient will demonstrate effective coping strategies within 48 hours.  
Nursing Interventions:  
- Provide emotional support and reassurance.  
- Encourage participation in relaxation techniques such as deep breathing exercises.  
- Facilitate communication with family members to provide additional support.  
Rationale:  
- Emotional support can help alleviate feelings of anxiety.  
- Relaxation techniques can reduce physiological symptoms of anxiety.  
- Family involvement can enhance emotional well-being.  
Evaluation:  
- Goal met; patient reports decreased anxiety and demonstrates use of deep breathing exercises.  
Revision (if goal was not met):  
- Consider referral to a mental health professional for further evaluation and support.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for nursing diagnoses, ensuring that all clinically relevant assessment data is meticulously captured. By incorporating high-search healthcare keywords, this template facilitates the accurate recording of respiratory status, vital signs, diagnostic test results, and other pertinent observations related to primary and secondary nursing diagnoses. Clinicians can efficiently document related factors, defining characteristics, and overall goals, while setting specific, measurable, and time-bound expected outcomes. The template also provides a structured approach to nursing interventions, complete with evidence-based rationales, enabling healthcare professionals to deliver targeted patient care. Evaluation sections allow for the assessment of goal achievement, with provisions for revising care plans if necessary. This template is an essential tool for enhancing clinical accuracy, improving patient outcomes, and optimizing nursing workflows. Explore and implement this template to elevate your clinical documentation practices.
Frequently Asked Questions

Common questions about this template and its usage

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Notes on Nursing Care Plans (NCP)