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    How To Write A Nursing Care Plan

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    Tyler Hemsworth
    This document outlines the key components and steps to writing an effective nursing care plan: 1. A nursing care plan includes components like nursing diagnosis, expected outcomes, interventions and rationales, and evaluation. 2. The steps to write a care plan are to assess the patient, determine a nursing diagnosis, establish SMART goals and a plan, implement interventions, and evaluate outcomes. 3. Core aspects of an effective care plan include ongoing assessment of the patient, clear diagnosis and goals, evidence-based interventions, and evaluation of progress.

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    How To Write A Nursing Care Plan

    Uploaded by

    Tyler Hemsworth
    185 views5 pages
    This document outlines the key components and steps to writing an effective nursing care plan: 1. A nursing care plan includes components like nursing diagnosis, expected outcomes, interventions and rationales, and evaluation. 2. The steps to write a care plan are to assess the patient, determine a nursing diagnosis, establish SMART goals and a plan, implement interventions, and evaluate outcomes. 3. Core aspects of an effective care plan include ongoing assessment of the patient, clear diagnosis and goals, evidence-based interventions, and evaluation of progress.

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    Nursing Care Plan

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    This document outlines the key components and steps to writing an effective nursing care plan: 1. A nursing care plan includes components like nursing diagnosis, expected outcomes, interventions and rationales, and evaluation. 2. The steps to write a care plan are to assess the patient, determine a nursing diagnosis, establish SMART goals and a plan, implement interventions, and evaluate outcomes. 3. Core aspects of an effective care plan include ongoing assessment of the patient, clear diagnosis and goals, evidence-based interventions, and evaluation of progress.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    185 views5 pages

    How To Write A Nursing Care Plan

    Uploaded by

    Tyler Hemsworth
    This document outlines the key components and steps to writing an effective nursing care plan: 1. A nursing care plan includes components like nursing diagnosis, expected outcomes, interventions and rationales, and evaluation. 2. The steps to write a care plan are to assess the patient, determine a nursing diagnosis, establish SMART goals and a plan, implement interventions, and evaluate outcomes. 3. Core aspects of an effective care plan include ongoing assessment of the patient, clear diagnosis and goals, evidence-based interventions, and evaluation of progress.

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    of 5

    How to Write a Nursing Care Plan

    How to Write a Nursing Care Plan

    Nursing Care Plan Components


    A nursing care plan has several key components including,

    • Nursing diagnosis
    • Expected outcome
    • Nursing interventions and rationales
    • Evaluation

    Each of the five main components is essential to the overall nursing process and care plan. A
    properly written care plan must include these sections otherwise, it won’t make sense!

    • Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for
    their patients
    • Expected outcome - The measurable action for a patient to be achieved in a specific time
    frame.
    • Nursing interventions and rationales - Actions to be taken to achieve expected
    outcomes and reasoning behind them.
    • Evaluation - Determines the effectiveness of the nursing interventions and determines if
    expected outcomes are met within the time set.

    How to Write a Nursing Care Plan


    Determine the patient's most significant issues prior to composing the nursing care plan.
    Consider both medical and psychosocial difficulties. At times, a patient's psychosocial concerns
    may be more pressing or even hold up his or her discharge than the patient's actual medical
    problems.

    After compiling a list of the patient's issues and the corresponding nursing diagnosis, you must
    determine which are the most significant. In general, this is done by contemplating the ABCs
    (Airway, Breathing, Circulation). However, these won't ALWAYS be the most significant or
    even pertinent for your patient.

    Step 1: Assessment

    The first step in writing an organized care plan includes gathering subjective and objective data.
    Subjective data is what the patient tells us their symptoms are, including feelings, perceptions,
    and concerns. Objective data is observable and measurable.

    This information can come from,


    • Verbal statements from the patient and family
    • Vital signs
    o Blood pressure
    o Heart rate
    o Respirations
    o Temperature
    o Oxygen Saturation
    • Physical complaints
    o Pain
    o Headache
    o Nausea
    o Vomiting
    • Body conditions
    o Head-to-toe assessment findings
    • Medical history
    • Height and weight
    • Intake and output
    • Patient feelings, concerns, perceptions
    • Laboratory data
    • Diagnostic testing
    o Echocardiogram
    o X-Ray
    o EKG

    Step 2: Diagnosis

    Using the information and data gathered in Step 1, the nursing diagnosis that best suits the
    patient, his or her hospitalization goals and objectives is selected.

    North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as "a
    clinical judgment about the human response to health conditions/life processes, or a vulnerability
    for that response, by an individual, family, group, or community."

    The nursing diagnosis is founded on Maslow's Hierarchy of Needs and assists with treatment
    prioritization. The next stage involves determining the goals for resolving the patient's problems
    through nursing interventions based on the nursing diagnosis selected.

    There are 4 types of nursing diagnoses.

    1. Problem-focused - Patient problem present during a nursing assessment is known as a


    problem-focused diagnosis
    2. Risk - Risk factors require intervention from the nurse and healthcare team prior to a real
    problem developing
    3. Health promotion - Improve the overall well-being of an individual, family, or
    community
    4. Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed
    through the same or similar nursing interventions

    After determining which type of the four diagnoses you will use, start building out the nursing
    diagnosis statement.

    The three main components of a nursing diagnosis are:

    1. Problem and its definition - Patient’s current health problem and the nursing
    interventions needed to care for the patient.
    2. Etiology or risk factors - Possible reasons for the problem or the conditions in which it
    developed
    3. Defining characteristics or risk factors - Signs and symptoms that allow for applying a
    specific diagnostic label/used in the place of defining characteristics for risk nursing
    diagnosis

    Examples:

    PROBLEM-FOCUSED DIAGNOSIS

    Problem-Focused Diagnosis related to ______________________ (Related Factors) as


    evidenced by _________________________ (Defining Characteristics).

    RISK DIAGNOSIS

    The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as
    evidenced by __________________________ (Risk Factors).

    Step 3: Outcomes and Planning

    After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-
    based practices. SMART is an acronym that stands for,

    • Specific
    • Measurable
    • Achievable
    • Relevant
    • Time-Bound

    It is essential to take into account the patient's medical diagnosis, overall condition, and all
    collected data. A physician or other advanced healthcare professional makes a medical diagnosis.
    It is essential to remember that a medical diagnosis does not change if the patient's condition
    improves, and it remains a permanent part of the patient's medical history.

    Examples of medical diagnosis include,


    • Chronic Lung Disease (CLD)
    • Alzheimer’s Disease
    • Endocarditis
    • Plagiocephaly
    • Congenital Torticollis
    • Chronic Kidney Disease (CKD)

    During this period, you will also consider the patient's goals and short- and long-term outcomes.
    These objectives must be achievable and desired by the patient. For instance, if a goal is for the
    patient to seek counseling for alcoholism during hospitalization, but the patient is currently
    detoxifying and experiencing mental distress, this goal may not be achievable.

    Step 4: Implementation

    Now that the objectives have been established, you must take the necessary steps to assist the
    patient in achieving them. While some actions will produce immediate results (e.g.,
    administering a suppository to a patient with constipation to induce a digestive movement),
    others may not be observed until later in the hospitalization.

    The implementation phase means performing the nursing interventions outlined in the care plan.
    Interventions are classified into seven categories:

    • Family
    • Behavioral
    • Physiological
    • Complex physiological
    • Community
    • Safety
    • Health system interventions

    Some interventions will be patient or diagnosis-specific, but there are several that are completed
    each shift for every patient:

    • Pain assessment
    • Position changes
    • Fall prevention
    • Providing cluster care
    • Infection control

    Step 5: Evaluation

    The fifth and final step of the nursing care plan is the evaluation phase. This is when you
    evaluate if the desired outcome has been met during the shift. There are three possible outcomes,

    • Met
    • Ongoing
    • Not Met

    On the basis of the evaluation, it can be determined whether the objectives and interventions
    need to be modified. Ideally, all nursing care plans, including objectives, should be met prior to
    discharge. This is not always true, particularly when a patient is being discharged to hospice,
    home care, or a long-term care facility. Initially, you will discover that the majority of care plans
    will have ongoing objectives that may be met within a few days or weeks. It depends on the
    patient's condition and the desired outcomes.

    Consider selecting objectives that the patient is capable of achieving. This will not only help the
    patient feel as though they are making progress, but it will also relieve the nurse by allowing
    them to monitor the patient's overall progress.

    Nursing Care Plan Fundamentals

    Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific
    nursing interventions, and an evaluation plan. The nursing plan is constantly updated with
    changes and new subjective and objective data.

    Key aspects of the care plan include,

    • Assessment
    • Diagnosis
    • Outcome and Planning
    • Implementation
    • Evaluation

    Through subjective and objective data, constantly assessing your patient’s physical and mental
    well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a
    helpful and powerful tool.

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