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A nursing care plan is an outline for nurses to document each patient's unique needs, as well as an implementation to meet those needs. It provides a way to organize the nursing process, as well as enabling effective communication between the nursing team and other peers such as doctors who may access these documents as well.

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Care plans are first typed electronically, then printed and put into organized files in each patient's health records. There are numerous ways a care plan may be distributed in the hospital. Doctors may read it before meeting with the patient to have a basic understanding of the information already collected, thus creating a more efficient process. Additionally, nurses may have their care plans peer-reviewed to see what other nurses may think about the individual's symptoms and needs. And finally, a nurse who is handing off a patient to another nurse will need to provide the receiving nurse the important information to properly care for the patient.

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Common moves when writing a nursing care plan. 

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Common moves when writing a nursing care plan. 

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Care plans typically require each of these sections:
1. Nursing diagnosis: The nursing diagnosis analyzes the scenario, and finds symptoms that may have been an outcome from the situation.
2. Subjective data: Subjective data is data that focuses on how the patient feels. Examples include: how much pain they feel on a scale of 1-10, or if they show signs of being under any emotional stress.
3.Objective data: Objective data focuses on the more factual data, such as: the age of the patient, what procedures has been done, the initial diagnosis, their vitals etc..
4.Nursing outcomes: Nursing outcomes are the goals the nurse hopes to achieve desirable outcomes for the patient. This is the planning stage of the care plan of what exactly the nurse wants to implement to care for their patient.
5.Nursing interventions: Nursing interventions is the implementation phase of the care plan, where they take their goals from the nursing outcomes, and describe what exactly they are going to do to achieve their foals from nursing outcomes.

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This nursing care plan for a Hysterectomy andincludes a diagnosis and care plan for nurses with nursing interventions and outcomes for thefollowing conditions: Risk for Infection and Grieving related to loss of body part. Patients who have underwent surgery for a hysterectomy, which is the removal of the female reproductive organs, are at risk for infection and may experience grieving related to the loss of the ability to have children. It is important to note that a hysterectomy can be a full or partial removal of the female reproductive organs. Sometimes only the uterus is removed, and the ovaries are left. In addition, the procedure may be performed vaginally or abdominally.

Why are hysterectomies performed? Hysterectomies are performed in patients that have cancer such as uterine, cervical, or ovarian, severe endometriosis, or vaginal prolapse, just to name a few.

Below is a case scenario that may be encountered as a nursing student or nurse in a hospital setting.

What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?

This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn't always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.

Nursing Care Plan for: Hysterectomy

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.

A 32 year old female is post-opt day 1 from a total hysterectomy. She was diagnosed with stage 1 ovarian cancer and a suspicious tumor was found in her uterus during the procedure (the results are still pending to know if it was cancer). VS are within normal limits. The patient has a foley catheter and a JP (Jackson-pratt drain). The patient had the hysterectomy via the abdomen. The patient's pain right now is a 2 on 1-10 scale and she is using a PCA pain pump with Dilaudid which is controlling her pain. The patient states she wished she would have had children in her early 20s if she knew she would be having a hysterectomy at 32 years old. She says she "majorly" regrets not having kids and wishes she wouldn't have focused so much on her career. She said her mom had the same procedure at 36 years old. The patient's voice becomes weak (like she is going to cry) and you notice she becomes teary eyed.

Risk for infection related to surgical intervention and presents of foley catheter as evidence by patient post-opt day 1 from abdominal total hysterectomy and indwelling foley catheter present.Grieving related to loss of body part and childbearing ability as evidence by patient reports "majorly" regretting not having children before hysterectomy.

The patient's pain right now is a 2 on 1-10 scale. The patient states she wished she would have had children in her early 20s if she knew she would be having a hysterectomy at 32 years old. She says she "majorly" regrets not having kids and wishes she wouldn't have focused so much on her career. She said her mom had the same procedure at 36 years old.

A 32 year old female is post-opt day 1 from a total hysterectomy. She was diagnosed with stage 1 ovarian cancer and a suspicious tumor was found in her uterus during the procedure (the results are still pending to know if it was cancer). VS are within normal limits. The patient has a foley catheter and a JP (Jackson-pratt drain). The patient had the hysterectomy via the abdomen.

Patient will remain free from infection throughout hospitalization.Patient will verbalize 3 ways to prevent surgical infection by discharge.Patient will demonstrate how to properly change wound dressing using clean technique by discharge.Patient will verbalize 3 ways of coping with the loss ability of childbearing by discharge.

Patient will identify 2 individuals of support she can talk to about her feelings of grief related to the hysterectomy by discharge.

The nurse will assess and report a temperature greater than 100.5 'F, high WBC, tachycardia, low blood pressure, and increased respiratory rate to md which may indicate infection.The nurse will assess the patient's wound for any purulent drainage or abnormal redness daily.

The nurse will remove the patient's foley catheter on post-opt day 3 per md order.

The nurse and all support staff will perform hand hygiene before and after patient contact.

The nurse will educate and demonstrate to the patient how to properly change her wound dressing using clean technique starting on post-opt day 2.

The nurse will help the patient identify 3 coping techniques she can use to help with the grief of losing the ability to bear children daily.

The nurse will help the patient identify 2 support individuals by discharge.

The nurse will provide the patient with local support groups she can attend to help with grieving by discharge.

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Nursing Care Plan & Diagnosis for Hysterectomy| Risk for Infection & Grieving

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This nursing care plan for a Hysterectomy andincludes a diagnosis and care plan for nurses with nursing interventions and outcomes for thefollowing conditions: Risk for Infection and Grieving related to loss of body part .

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A good care plan will effectively communicate the patient's symptoms, situation, medicine needed/other care needed, the nurse's hopeful outcome for these implementations, and any objective or subjective data that may be deemed important to know.

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In the health care field, it is important to make sure all documents are consistent and not cluttered with unnecessary words or sentences. Because of this, all care plans are organized the same way, and use specific medical field lexus and are very straightforward in the telling of information.

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Common language features in care plans include writing in the third person, even when you are writing about yourself. This includes using words and phrases such as: "The patient feels sick. "The patient expresses feelings of anxiety." "The nurse will prescribe penicillin to the patient."

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Care plans effectively communicate to nurses, doctors, and any other health care peer the patient's needs and care plan through its consistent structure and simple and concise word choice to give the most amount information as possible with the least amount of reading. This is especially important in a fast paced setting such as hospitals, where anything can happen at any time.