Nurse Template

Nursing Care Plan (NCP) Notes

A professional Nurse template for healthcare professionals.

About this template

The Nursing Care Plan (NCP) Notes template is an essential tool for nurses to document comprehensive care plans for patients. This template is designed to capture detailed assessment data, nursing diagnoses, related factors, and defining characteristics. It also outlines overall goals, expected outcomes, and specific nursing interventions with rationales. Nurses can use this template to evaluate patient progress and make necessary revisions to the care plan. Ideal for use in various healthcare settings, this template ensures a structured approach to patient care, promoting effective communication and continuity of care among healthcare professionals.

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Clinically Relevant Assessment Data: - Nursing Diagnosis #1: Patient presents with impaired gas exchange, NANDA code 00030. Assessment findings include 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 exhibits 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: - Improve oxygenation and respiratory function. Expected Outcomes: - Oxygen saturation will increase 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: - Reduce anxiety levels and improve 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.

Clinically Relevant Assessment Data: - [describe cluster of assessment data for Nursing Diagnosis #1] (include all relevant assessment findings, such as respiratory status, symptoms, vital signs, diagnostic test results, history, and other pertinent observations related to the primary nursing diagnosis.) - [describe cluster of assessment data for Nursing Diagnosis #2] (include all relevant 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.)

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