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The document is a sample nursing care plan created by a 2nd semester junior nursing student, focusing on a patient with a gangrene-infected left foot due to diabetes-related complications. It includes objective and subjective assessments, medical diagnoses, nursing diagnoses, patient outcomes, interventions, rationales for the interventions, and evaluations of outcomes. The primary goal is to manage the patient's wound care effectively while addressing pain and promoting healing.

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What does a good care plan look like?

Every care plan should include: A discussion around health and well being goals and aspirations. A discussion about information needs. A discussion about self care and support for self care. Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes.

What is an example of a care plan?

One example of a standardized care plan is the post-operative care pathway used in post-surgical units. These post-operative care plans outline expected goals for each post-operative day. However, standardized care plans should be tailored when possible to the needs of the individual patient.

What is a basic care plan?

A care plan helps nurses and other care team members organize aspects of patient care ing to a timeline. Its also a tool for them to think critically and holistically in a way that supports the patients physical, psychological, social and spiritual care.

How do you write a care plan example?

The plan should include important information about the person receiving care, including their: Name, date of birth, and contact information. Health condition(s). Medicines, dosages, and when/how they are given. Health care providers with contact information. Health insurance information. Emergency contacts.

What are the 5 components of a nursing care plan?

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

nursing care plan template word

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How do you write a simple nursing care plan?

Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation. Assess the patient. The first step to writing a care plan is performing a patient assessment. Make a diagnosis. Set goals and outcomes. Determine nursing interventions. Evaluate the plan.

What is the format of a nursing care plan?

Nursing care plan formats are usually categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation.

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