A student Nursing Care Plan (NCP) refers to the care plans developed by nursing students as part of their education and clinical training. These care plans are created by nursing students to demonstrate their understanding and application of the nursing process in providing patient-centered care. Typically, they apply a 6-column format.
Review: Nursing Care Plans Writing Guide:
Components of a Student Nursing Care Plan
Here’s a breakdown of the components in the 6-column format:
- Assessment: This column includes the relevant subjective and objective assessment data or defining characteristics obtained during the patient assessment.
- Nursing Diagnosis: This column identifies the nursing diagnosis or problem based on the assessment data, utilizing standardized nursing taxonomies such as NANDA-I.
- Desired Outcomes: This column specifies the measurable and time-bound goals or expected outcomes related to the nursing diagnosis. These outcomes should be realistic and achievable.
- Nursing Interventions: This column lists the nursing interventions or actions to be implemented to address the nursing diagnosis and achieve the desired outcomes. These interventions should be evidence-based, individualized, and specific to the patient’s needs.
- Rationale: This column provides the scientific or clinical justification for selecting and implementing the nursing interventions. It explains the reasoning behind the chosen interventions and how they are expected to impact the patient’s condition.
- Evaluation: This column documents the assessment of the patient’s response to the nursing interventions and the achievement of the desired outcomes. It involves evaluating the effectiveness of the care plan, comparing the patient’s progress to the desired outcomes, and making any necessary modifications.
- The 6-column format allows nursing students to demonstrate a more comprehensive understanding of the nursing process and critical thinking skills. It encourages students to consider the rationale behind their chosen interventions and evaluate the effectiveness of their care.
- However, it’s important to note that the specific format and number of columns used in student nursing care plans may vary depending on the educational institution and the preferences of the faculty or clinical instructors.
Student (6- Column) Nursing Care Plans Examples
Here are examples of tabular 6-column nursing care plans for the nursing diagnoses of hypertension, pneumonia, risk for infection, anxiety, COPD, risk for falls, acute pain, impaired skin integrity, urinary tract infection (UTI), and psychosocial:
A. Student NCP on Hypertension Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Objective: Blood pressure consistently above 140/90 mmHg. | Hypertension related to elevated blood pressure. | – Patient’s blood pressure will be within normal range (< 120/80 mmHg).
– Patient will demonstrate understanding of hypertension management. |
– Monitor blood pressure regularly and record readings.
– Encourage adherence to prescribed antihypertensive medications. – Provide education on lifestyle modifications such as a low-sodium diet and regular exercise. |
– Regular blood pressure monitoring helps assess effectiveness of treatment.
– Medication adherence aids in controlling blood pressure. – Lifestyle modifications reduce hypertension risk. |
– After one month, patient’s blood pressure consistently falls within normal range.
– Patient demonstrates understanding of hypertension management and implements lifestyle modifications. |
B. Student NCP on Pneumonia Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Subjective: Patient reports productive cough and difficulty breathing.
Objective: Elevated temperature, crackles on lung auscultation. |
Impaired Gas Exchange related to pneumonia. | – Patient will demonstrate improved oxygenation and breathing pattern.
– Patient’s temperature will return to normal range. |
– Monitor oxygen saturation and respiratory status.
– Assist with effective coughing and deep breathing exercises. – Administer prescribed antibiotics and antipyretics as ordered. |
– Monitoring oxygenation ensures adequate gas exchange.
– Breathing exercises help clear respiratory secretions. – Medications treat infection and fever. |
After one week, patient shows improved oxygenation, normal temperature, and decreased respiratory symptoms. |
C. Student NCP on Risk for Infection Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Objective: Open surgical incision, compromised immune system. | Risk for Infection related to surgical incision and compromised immunity. | – Patient will maintain intact surgical incision with no signs of infection.
– Patient will demonstrate understanding of wound care and infection prevention measures. |
– Monitor surgical incision for signs of infection such as redness, swelling, or drainage.
– Educate patient and family on proper wound care techniques. – Promote hand hygiene and infection control practices. |
– Early detection of infection prevents complications.
– Patient education empowers self-care. – Infection control practices reduce the risk of infection transmission. |
After discharge, patient maintains intact incision and demonstrates proper wound care practices to prevent infection. |
D. Student NCP on Anxiety Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Subjective: Patient reports difficulty sleeping and feeling anxious.
Objective: Increased heart rate, restlessness, and decreased sleep duration. |
Anxiety related to situational stress. | – Patient will report decreased anxiety levels.
– Patient will demonstrate improved sleep patterns. |
– Use therapeutic communication techniques to provide emotional support.
– Teach relaxation techniques and coping strategies. – Administer prescribed anti-anxiety medications as ordered. |
– Providing emotional support helps alleviate anxiety.
– Teaching relaxation techniques promotes relaxation and stress reduction. – Medications can help manage anxiety symptoms. |
After two weeks, patient reports decreased anxiety levels and improved sleep patterns. |
E. Student NCP on COPD (Chronic Obstructive Pulmonary Disease) Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Objective: Shortness of breath, wheezing, decreased oxygen saturation. | Impaired Gas Exchange related to COPD. | – Patient will maintain adequate oxygenation with oxygen saturation above 90%.
– Patient will demonstrate effective breathing techniques. |
– Monitor oxygen saturation and respiratory status.
– Assist with proper positioning to facilitate breathing. – Encourage pursed-lip breathing and deep breathing exercises. – Administer prescribed bronchodilators and oxygen therapy as ordered. |
– Monitoring oxygenation helps ensure sufficient gas exchange.
– Positioning and breathing exercises aid in expanding the lungs. – Medications improve airway dilation and oxygenation. |
– After interventions, patient’s oxygen saturation remains above 90%.
– Patient demonstrates effective breathing techniques and reports improved respiratory comfort. |
F. Student NCP on Risk for Falls Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Objective: History of previous falls, impaired balance, use of assistive devices. | Risk for Falls related to impaired mobility and balance. | – Patient will remain free from falls during hospitalization.
– Patient will demonstrate safe ambulation and use of assistive devices. |
– Conduct fall risk assessment using standardized tools.
– Implement fall prevention strategies (e.g., keep the environment clutter-free, provide non-slip footwear). – Educate patient on proper use of assistive devices. – Provide assistance and supervision during ambulation as needed. |
– Fall risk assessment identifies factors requiring intervention.
– Environmental modifications and education promote safety. – Supervision and assistance minimize fall risk. |
– Patient remains free from falls throughout hospitalization.
– Patient demonstrates safe ambulation and proper use of assistive devices. |
G. Student NCP on Acute Pain Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Subjective: Patient rates pain as 8/10.
Objective: Guarding behavior, facial grimacing. |
Acute Pain related to surgical incision. | – Patient’s pain will be reduced to a tolerable level (< 4/10).
– Patient will utilize pain management techniques effectively. |
– Assess pain intensity using a standardized pain scale.
– Administer prescribed analgesics as ordered. – Provide comfort measures (e.g., positioning, warm compresses). – Teach relaxation techniques and guided imagery. |
– Regular pain assessments ensure appropriate pain relief.
– Medications address pain intensity. – Comfort measures and relaxation techniques promote pain reduction. |
– After interventions, patient reports pain reduced to a tolerable level (< 4/10).
– Patient utilizes pain management techniques effectively. |
H. Student NCP on Impaired Skin Integrity Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Objective: Presence of pressure ulcers on sacral area. | Impaired Skin Integrity related to pressure and immobility. | – Patient’s skin will remain intact and free from new pressure ulcers.
– Existing pressure ulcers will demonstrate signs of healing. |
– Conduct a thorough skin assessment and document the location, size, and characteristics of pressure ulcers.
– Implement pressure redistribution strategies (e.g., regular repositioning, use of specialized mattresses or cushions). – Provide meticulous wound care and dressings as ordered. – Educate patient and caregivers on skin care and prevention of pressure ulcers. |
– Accurate assessment guides appropriate interventions.
– Pressure redistribution and wound care promote healing. – Patient and caregiver education helps prevent future ulcers. |
– Over time, patient’s skin remains intact without new ulcers.
– Existing ulcers demonstrate signs of healing. – Patient and caregivers demonstrate understanding of preventive skin care measures. |
I. Student NCP on Urinary Tract Infection (UTI) Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Objective: Presence of dysuria, frequency, and cloudy urine. | Risk for Infection related to urinary catheter and compromised urinary tract. | – Patient will remain free from signs and symptoms of UTI.
– Patient will demonstrate understanding of preventive measures. |
– Assess urinary catheter and perineal area for signs of infection.
– Encourage fluid intake to promote urinary flushing. – Ensure proper catheter care and maintenance. – Educate patient and caregivers on hygiene practices and signs of UTI. |
– Regular assessment helps identify early signs of infection.
– Hydration and proper catheter care reduce bacterial growth. – Education empowers patient and caregivers to prevent infection. |
– Throughout the care period, patient remains free from signs and symptoms of UTI.
– Patient and caregivers demonstrate understanding and adherence to preventive measures. |
J. Student NCP on Psychosocial Nursing Diagnosis:
| Assessment | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|
| Subjective: Patient expresses feelings of sadness and loss of interest in activities.
Objective: Social withdrawal, tearfulness. |
Risk for Impaired Social Interaction related to depressive symptoms. | – Patient will engage in social interactions with peers and healthcare providers.
– Patient will verbalize improved mood and interest in activities. |
– Assess patient’s psychosocial needs and preferences.
– Encourage patient’s participation in group activities and therapy sessions. – Use therapeutic communication techniques to provide emotional support. – Collaborate with the healthcare team to develop a plan for managing depressive symptoms. |
– Addressing psychosocial needs promotes social interaction and improves mood.
– Group activities and therapy provide opportunities for social engagement. – Emotional support enhances patient’s well-being. |
– Over time, patient actively engages in social interactions.
– Patient expresses improved mood and interest in activities. |
- Please note that these are simplified examples, and in actual nursing care plans, additional assessments, interventions, and evaluations may be included based on the individual patient’s needs and clinical situation.