Nursing Paperwork:
Concept maps and Care plans
APA, Teaching-Learning, Evaluations...
Really are your friends...

Now, I did not used to feel this way either. It was all so global and confusing. Right now simply caring for your patients, introducing yourselves, remembering to get their name and date of birth (verifying), assessing, wrapping your brain around their diagnosis and treatment is hard enough. Please understand that this is to be expected ;)
However, it will not always be this way and it will get easier. I promise!

How many of you have ever had the English exercise where you were told to write directions on how to do something. (Actually, I hated this exercise. It seemed so pointless).

Write directions on how to make a peanut butter and jelly sandwich....OK...

I get the bread,
I get the peanut butter and jelly...and a knife.
I put the bread on a plate.
I open the peanut butter, put the knife in, get peanut butter on the knife, take it out and spread it on the bread...

And so forth and so on...
Oh so tedious....

*In essence when we ask for a care plan, we are saying give me directions on how you plan to care for your patient...
A care plan is just a plan of care!

Where do I start? The six steps!

Identify problems from your assessment, the database may or may not be up to date
Then prioritize the problems with the use of a concept map...

Turn problems into Nursing Diagnoses:
Define your nursing diagnosis...Check out NANDA.
A nursing diagnosis is not a medical diagnosis.
Nursing diagnoses can be grouped in various ways:

Maslow's hierarchy of needs:
> physiological needs
>safety and security needs
>love and belonging
>self esteem
>self actualization

Gordon's Functional Health Patterns:
> Health perception/health management
> Nutritional-metabolic pattern
> Elimination pattern
> Activity-exercise pattern
> Sleep-rest pattern
> Cognitive-perceptual pattern
> Self perception self concept patterns
> Role relationship pattern
> Sexuality-reproductive pattern
> Coping-stress tolerance pattern
> Value-belief pattern

Doenges and Moorhouse's diagnosis framework
> Activity/rest
> Circulation
> Ego Integrity
> Elimination
> Food/Fluid
> Hygiene
> Neurosensory
> Pain/Discomfort
> Respiration
> Safety
> Sexuality
> Social Interaction
> Teaching/Learning

NANDA's domains of nursing diagnosis
> Health Promortion
> Nutrition
> Elimination/exchange
> Activity/rest
> Perception/cognition
> Self-perception
> Role relationships
> Sexuality
> Coping/stress tolerance
> Life principles
> Safety/protection
> Comfort
> Growth/development

*Use modifiers, decreased, ineffective, altered, impaired, at risk for...

*Expand upon for nursing diagnosis - is related to (r/t) as evidenced by (aeb)
For example, Pain related to a surgical incision as evidenced by grimacing, crying, FACE =8/10, ...

Related to, r/t...pathophysiological, environmental, psychosocial, spiritual, cultural, situation, developmental level...Note these must be modifiable by a nursing intervention.

As evidenced by, aeb, often the answer to this was noted in your interview or assessment.
Pain r/t surgery aeb grimacing, flacc, face or number = 8, immobility, crying...
Ineffective oxygenation r/t constricted airways aeb SOB, tachypnea, tripoding, retractions, O2 sat<94%

This is one of your care goals for your patient.
After you have your nursing diagnosis, determine an outcome or goal for your patient.
The outcome must be measurable...if the child has had a procedure which causes pain, a measurable goal could be that before I leave today I want to have maintained his pain at a level of < 3.
At the end of the day you will evaluate this outcome...
Was I able to keep the pain level down below 3?
I like to do it in this order so that the care I provide has meaning.

If for example, the child is 4 days post-op and no longer in pain but bored or afraid, then the goal I set is pointless.

The goal will determine my interventions.
If my child is in pain I am going to assess the pain using the appropriate measure, then provide distraction, possibly warm or cool compresses, and later I will try medication... and so forth and so on.
You need at least 3 interventions per nursing diagnosis.

If my child is in respiratory distress, I will intervene in appropriate ways to maintain oxygenation i.e. assessing respiratory status: rate, rhythm, ease, O2 sat readings. I may then intervene with position changes, O2 via nasal canula, etc.

I need to be able to explain why I intervened like I did.
Why did I use a FLACC or FACE pain assessment scale (age).
I need to provide a reason I tried distraction. Did I try sweetease or a movie? Was it age appropriate?
Why did I then administer a pain medication?
If I assessed the respiratory status, this is to maintain homeostasis. Respiratory distress can lead to....

Lastly, I will evaluate my care.
The patient and family are evaluating your care; this is no different.
Did I make sure to focus on the mainproblems? (Pick the most important diagnoses)
Did I set a measureable goal? (< 3 on FLACC, FACE or Number pain scale, O2 sat >94%)
If I performed patient teaching, I can still measure the results by having the patient acknowledge understanding through a return demonstration.

More and more in our documentation insurance companies are going to evaluate outcomes.
If I teach a client, it is not billable unless I include that the patient acknowledged understanding and returned a demonstration. See, returning an accurate demonstration indicates understanding; it is measurable.

An excellent video which details how to write a Care Plan/Map

Links for nursing diagnoses, outcomes classification and interventions

Link to the U.S. National Library of Medicine, Institute of Health concerning nursing diagnoses:
Nursing diagnoses

Link to U.S. National Library of Medicine, Institute of Health concerning nursing outcomes classification:
Nursing outcomes classification

Link to U.S. National Library of Medicine, Institute of Health concerning nursing interventions classification:
Nursing interventions outcomes

The PowerPoint below addresses much of the other required paperwork for the nursing program.
APA, Teaching-Learning and Clinical Evaluations

This is a link to an amazing resource by the American Psychological Association about APA formatting. It is a brief voice over PowerPoint tutorial with several examples.

The Owl of Purdue for excellent guidance on APA

Did you know that if you are leaving the floor, going to post conference, or changing patients you must report off, even as a student, to the nurse in charge or it could be considered patient abandonment? SBAR provides an excellent way to give a quick, relevant report to the nurse. Also, did you know that more and more end of shift reporting is being done at the bedside?

A breakdown of SBAR...
Tell the person you are reporting to who your are, who you are reporting about, why you are reporting and what is going on...
What has lead up to this...
Current data, why are we calling him...description of status, not diagnosis
Suggestion for care related to labs, medications, care

Just for fun, be careful what you write...
Chart and Documentation Bloopers!


Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families (3rd ed.). New York, NY: Delmar Cengage Learning.

Schuster, P. M. (2012). Concept Mapping: A critical thinking approach to care planning (3rd ed.). Philadelphia, PA: F. A. Davis Company.

Videos located at:

Care Plans


Chart and Documentation Bloopers