Nursing Care Plan Template for Nursing Students

Nursing Care Plan Template for Nursing Students

Your instructor will give you a case study or patient scenario to write a nursing care plan. Some instructors also allow you to develop a nursing case study and write an appropriate nursing care plan. You can also use a real case from your shadowing, internship, or practicum experience. Whichever the case, you can use the template below if none is given. You should organize the nursing care plan into columns for easier entry and organization. Your introduction should briefly revisit the case study. If requested, expound on the etiology of the medical diagnosis in the background section. The next section is your nursing care plan with columns of assessment, diagnosis, goals and outcomes, interventions, and evaluation, making it 5 columns. Some instructors only want three columns for nursing diagnosis, outcomes and evaluation, and interventions, while others insist on four columns for nursing diagnosis, goals and outcomes, interventions, and evaluation. Below is an example of the nursing care plan section:

Nursing Diagnosis	Goal/Expected Measurable Outcomes	Nursing Interventions	Underlying Scientific Principles of Nursing (Rationale)	Evaluation

  The next section can include discharge planning, medication management, rest and activities, diet planning, ongoing care, sleeping, and follow-up. Finally, write a conclusion that summarizes the entire nursing care plan and include a list of the references you used when writing the nursing care plan.

Sample Nursing Care Plan for Schizophrenia

Nursing Diagnosis: Ineffective coping skills and risk for hematologic side effects of Clozapine Goals and expected outcomes

• To remain stable on medication and to transition into a less restrictive environment.
• Adequate rest and nutritional intake
• Establish communication and build trust, and encourage patients to participate in the therapeutic community.
• Increase ability to communicate with others.
• Symptom management; decrease in hallucination, delusions, and other psychotic features such as self-talk
• Increase self-esteem
• Subjective and Objective reduction of psychotic symptoms (an irrational behavior)
• Adhere to recommended therapy, including medications, psychotherapy, and lab appointments for hematology.

Nursing Interventions

• Assist the patient in identifying strengths and coping abilities (nursing interventions). Strength-based approaches help better recover schizophrenic patients (Xie, 2013). Emphasis on strength is a positive coping mechanism proven to buffer the impact of negative symptoms and promote rehabilitation of patients with schizophrenia (Tian et al., 2019). (rationale)
• Meet monthly with the clinical team. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Obtain weekly Vital Signs. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Encourage all medications as prescribed. Adherence to pharmacological treatment helps alleviate the psychotic symptoms of schizophrenia, v. Non-adherence could lead to deterioration of the symptoms (El-Mallakh & Findlay, 2015).
• Provide opportunities for self-reflection, self-care, positive self-image, and effective communication. Encouraging healthy habits among schizophrenic patients helps optimize functioning, such as drug adherence, maintenance of sleep, reduced stress levels, self-care maintenance, and anxiety (Tian et al., 2019).
• Encourage outings and identify opportunities to reduce anxiety -enjoy music, poetry, and creative writing, and connect with a church spiritual group. Empathy helps the patient perceive the caregivers as caring and makes them feel accepted. It also helps the patients maintain positive coping mechanisms (Peixoto, Mour'o, & Serpa Junior, 2016).
• Monitor lab results (WBC and ANC) and report significant changes per Clozapine guidelines. Patients taking Clozapine must be monitored frequently as they are more predisposed to serious blood dyscrasias. In addition, discontinuing WBC monitoring after 6 months of starting the drug could lead to mortality and accidents (Kar, Barreto & Chandavarkar, 2016).
• Monitor for hematologic side effects: Neutropenia, leukopenia, agranulocytosis, and thrombocytopenia (secondary to bone marrow suppression caused by Clozapine). Clozapine has serious side effects such as seizures, cardiomyopathy, myocarditis, cardiomyopathy, neutropenia, ad agranulocytosis (Dixon & Dada, 2014).
• Instruct patient to report any side effects, illness, s/s of infection, fatigue, or bruising without apparent cause. Constant monitoring of psychotic symptoms helps change treatment (Holder, 2014). For instance, it can help determine if the antipsychotic medication is not working and include evidence-based psychosocial interventions (Stroup & Marder, 2015).
• Monitor anticholinergic effects; dry mouth, difficulty urinating, constipation.
• Monitor for reduction/increase of psychotic symptoms
• Discourage caffeine. Caffeine interacts with Clozapine and can lead to toxicosis. It increases the plasma concentrations of Clozapine (De Berardis et al., 2019). Caffeine inhibits the metabolism of Clozapine through the inhibition of CYP1A2 (Delacr�taz et al., 2018)

Evaluation

• The patient will have reduced symptoms, adhere to medication, and show improvement.
• The patient will control his feelings, perceptions, and thought processes.
• Social increasing ease of communication since starting Clozaril (date). The patient will easily interact with caregivers, family, and other patients.
• The patient will acknowledge the importance of medication in lowering suspicion.
• Self-talk has diminished since admission. The patient will also exhibit high self-esteem levels.
• The patient will have reduced anxiety and violent behavior and have remission.

References Brekke, I. J., Puntervoll, L. H., Pedersen, P. B., Kellett, J., & Brabrand, M. (2019). The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS one, 14(1), e0210875. https://doi.org/10.1371/journal.pone.0210875 De Berardis, D., Rapini, G., Olivieri, L., Di Nicola, D., Tomasetti, C., Valchera, A., ... & Serafini, G. (2018). Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of Clozapine. Therapeutic advances in drug safety, 9(5), 237-256. Delacr'taz, A., Vandenberghe, F., Glatard, A., Levier, A., Dubath, C., Ansermot, N.,  Eap, C. B. (2018). Association Between Plasma Caffeine and Other Methylxanthines and Metabolic Parameters in a Psychiatric Population Treated with Psychotropic Drugs Inducing Metabolic Disturbances. Frontiers in psychiatry, 9, 573. https://doi.org/10.3389/fpsyt.2018.00573

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