Sample of Nursing Care Plan

Nursing care plan is also known as Nursing Diagnosis plan, which offers the nursing care to the patient who suffers from any type of ailment. There are a few key steps that one needs to remember in order o write the Nursing care plan.
The Nursing care plan primarily focuses on

• Actions that solve existing problems.
• Relation with the future.
• identifying health and nursing problems.

The Sample nursing care plan will give you an idea how to write the nursing care plan when you work in a health care facility.

Patient Information
Name                                     Medical Record                             Room No
Helen Crawford                   Memory Impaired…..                             27
Date
8/10/2009
Problem/Action
COGNITIVE AND COMMUNICATION
Cognitive function level is altered due to …..  of ……
Client has problems with decision making, inability to comprehend and memory problems.
Also find it problematic to being understood or understand, whatever is said to him.

Goal

Client would be oriented to continuous care for 2 months.
Client will start recovering and able to show improvement sign on a daily basis
Client will start understanding whatever is said to him
Client memory start showing improvement
Demonstrate ability to comprehend
Approach/Intervention
Introduce yourself and inform the patient what action you are planning.
To help name recognition, start calling client by name in every interaction.
Not to complicate his memory, tell him just one idea, thought or command.
Maintain same routine everyday to prevent confusion.
Avoid presenting conflicting ideas for his easy grasp.
Simply ask in affirmative yes or negative no to understand the need of the client.
Use simplest form of oral and concrete language, while communicating with the client
Assist in improving  decision making skill
Psychiatric evaluation if indicated