How to Write a Nursing Care Plan
How to Write a Nursing Care Plan
A nursing care plan is an essential nursing process that outlines the plan of action that a nurse will be executing during a patient’s medical care. Both licensed practical nurses and registered nurses routinely complete a care plan once a detailed assessment has been performed on the patient’s present medical condition and after medical history. After all these, nurses can then implement the care plan goals and objectives.
Now you have seen how important and unavoidable nursing care plans are in either nursing school or nursing workplace. In a nursing school, your professor will require you to learn to write detailed nursing care plans, process the information, think and execute them like a professional nurse. To acquire a good skill of writing good nursing care plans you ought to write many care plan assignments throughout tour learning years. As such, learning how to write nursing care plans is essential if you want to become a professional nurse.
Why do Nursing Care Plans Matter?
Nursing Care Plans are written medical documents that play an integral part in the nursing procedure. Although various places may use different care plan methods, the final document often achieves the same goals intended in every place. Essentially, nursing care plans often guide the nurses on how to provide nursing care to patients. The document guides different nurses working in different shifts to know what actions other nurses have taken for each patient they are caring for. As such, nursing care plans are a regularly reliable way of organizing and communicating nursing actions to anyone involved in patient care.
In a more direct way, nursing care plans document assesses diagnoses, plans interventions and evaluation. When documented, a nurse can handle each process hassle-free. Once you master how to write nursing care plans, your confidence as a nurse will increase while you are likely to get higher grades as a nursing student.
How to write a Nursing Care Plan – 5 Steps to Follow
Even though nursing care plans don’t follow the exact same format in all places, these five steps will give you a document that satisfies the stand nursing care plan requirements. The steps include;
- Implementation of nursing orders
Without much ado, let’s look at each step in details and see how it contributes to the final and comprehensive nursing care plan document.
Step One: Assessment
When writing a nursing care plan, assessment is always the first step of the process. Before or as you fill the assessment template, there are important questions you ought to answer. For instance, why is the patient here? Why is he/she seeking medical care? What is the general appearance of the patient? In a nutshell, assessment entails collecting and recording different kinds of patient data. Assessment needs to be done in an accurate and comprehensive manner.
The American Nurses Association asserts that when writing care plans, you should collect physiological, economic, sociocultural and spiritual data of the patient. Besides, lifestyle information has to be captured as well. Generally, assessment endeavors to understand the physical causes of pain, ways it manifests, and how the patient responds. The assessment section should be as brief as possible just like any other sections included in an excellently written care plan.
The diagnosis section mainly focuses on “What” of the patient’s condition. Under this section, you will concentrate on answering the question: “What is the patient’s problem?” The answer to this question will help the nurse decide the kind of care the patient will get. Besides, the diagnosis section lists the health conditions the patient is suffering in order to create a nursing diagnosis statement.
The North American Nursing Diagnosis Organization-International has categorized nursing diagnosis into four.
Actual Diagnosis: These are existing health issues that a nurse can actually identify. According to NANDA-I actual diagnosis makes a clinical judgment about how the patient experiences or responds
Risk Diagnosis: This diagnosis describes human responses to life processes or health issues that may occur in an individual, family or community. Certainly, the family or community is not facing health condition but may remain vulnerable.
Health Promotion Diagnosis: This refers to a clinical decision regarding the motivation of an individual, family or community to increase wellbeing. According to NANDA-I, motivation gets expressed as readiness for particular health behavior.
Syndrome Diagnosis: This refers to a clinical decision that describes a particular cluster of nursing diagnoses that often occur together. These kinds of diagnoses often get addressed together as well as require the same interventions. Whenever you are writing syndrome diagnosis, ensure you have used at least two diagnoses as defining characteristics.
Is nursing Diagnosis Different from Medical Diagnosis? Write the correct Diagnosis!
According to NANDA-I, a nursing diagnosis describes a patient’s responses to actual health issues or potential health issues. On the contrary, medical diagnosis defines a disease or injury process. Besides, only a doctor can write a medical diagnosis.
Step Three: Planning
In this section, you are required to set a specific, measurable and attainable aims that guide the care for the patient. You must determine the short-term and long-term goals that the patient will pursue. For instance, if the patient is immobilized, you can set a goal like – the patient will move from bed to chair at least three times a day or the patient will report decreased nausea within 12 hours. The bottom line is, the goals must be clear and measurable, and everyone involved understands what each goal means.
Step Four: Implementation/ intervention
This section mainly focuses on assisting the patient and caregivers attain the expected outcomes. Each patient nursing care plan has its own specific actions that nurses will require to implement. As such, you are required to write down the real actions that need attention. Include how frequent and how long. For example, a nurse should monitor and assess the patient’s nausea every 6 hours.
Step Five: Evaluation
Once you have implemented your nursing care plan, you must constantly keep evaluating your patient’s health status or wellness. Besides, you must also evaluate the effectiveness of your nursing care plans. The evaluation section of your care plan must carefully deliberate each goal set for the patient. In this section, a goal is either met or unmet. If your goal is unmet, consider revisiting the diagnosis step. You can also consider modifying the goals or include more interventions.
Although it is not often included, for academic purposes your professor may require you to include it in your nursing care plans. Writing nursing rationale can be a bit confusing, but a better understanding of how they interact with your nursing diagnoses, care goals and interventions will make it easier to write. In a nutshell, nursing rationale explains why you choose to set a certain goal or specific intervention. Bear in mind that each nursing intervention requires a nursing rationale. Here is a nursing rationale example;
Pain control will assist the patient in mending their life by allowing them to take part in physical therapy exercises.
What are the differences between care plans in nursing schools and care plans on the job?
Certainly, there is a small difference existing between care plans a nursing student writes in school and the care plans a registered nurse completes in a nursing job setting. Here are some of the differences:
Nursing care plans in nursing school
They are comprehensive and detailed. It is basically done so that the student can be familiar with the care plan development processes.
Mostly completed on a blank piece of paper and each section must be done manually. As such, it requires a lot of research and time to complete.
It requires a NANDA Nursing Diagnosis book to guide you when choosing a diagnosis.
Care Plans on the Job
Not detailed. A nurse is only required to list as many interventions or outcomes as possible. Instead of concentrating on comprehensive diagnosis statement, if mainly focuses on what you need to have.
They are often created on pre-made templates that are “diagnosis-specific” for a patient. The templates feature small boxes where you tick or check thus reduces completion time significantly.
These care plans are usually completed and stored electronically in most medical facilities. However, some can also be printed on templates.
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