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Hey guys we are going to be talking about creating a nursing care plan and nursing diagnosis for your patient in less than 10 minutes I want you to head over to NRS NG comm backslash care plan template to download the free care plan template that the NRS NG team has created for you guys going to be covering a few of my personal tips and tricks that I have on when you get stuck on doing a nursing care plan, and you're like I literally have nothing I don't know what we're going to do for this patient I have a few kinds of things that I just go over every single time for every patient to make sure you know usually that patient has one of those things that you can write about so alright I am going to start off by showing you our care plan template, so this is what you should download at NRS NG combat slash care plan template it starts off in the left column you will write your nursing diagnosis, and you know or plural you can have more than one you will then write down patient goals then interventions and the rationales behind your interventions whether you implemented them throughout your shift and this is based on your shift if you are not able to implement it just because you have a plan to do something might come up you may not be able to implement it that's okay it's not a failure to put no sometimes it's not sometimes appropriate you plan for something and the patient took a turn for something completely different so the other thing is the evaluation and the outcome of your nursing interventions, so I'm going to read off a little of a patient assessment for you, and then I'm going to go through my thought process on getting a diagnosis and a care plan put together for you guys patient presents to the emergency department with complain of a suicide attempt I know this is a little dark but this happens all the time per patients mother states I walked into his room and I found him with a rope around his neck he was standing on a chair and I yelled Jack he looked up at me and kicked the chair out from under his feet I grabbed the rope, and he yanked it down off of the ceiling fan and quote from mother the patient reports that he had been feeling really sad ever since his girlfriend broke up with him a couple of months ago, and today she was they were texting back and forth he texted her, and she said to stop contacting her and that she wishes they had never met so upon an inspection of his neck there are visible bruising marks from the noose on the underside of his chin and on the sides of the neck but there aren't any broken skin wounds or any bleeding anywhere the skin is completely intact and the patient also has as well multiple crosswise cuts on the wrist bilaterally that mom nor patient hadn't really talked about that you just noticed upon inspection so no bleeding of the wounds, but they do look fresh they do look like they've happened recently the patient is alert and oriented times for the lung sounds are clear to auscultation, and they...
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