How to Write Nursing Care Plans
Nursing care plans are unavoidable in nursing school and nursing workplaces. That’s why you must learn how to write nursing care plans. Your professor needs detailed nursing care plans. They want you to learn how to process information and think like a professional nurse. That explains why your teacher wants you to write nursing assignments all of the time. You’ll write nursing care plans, whether the class is community care or mental health. Learning how to write nursing care plans is critically important for anyone who wants to become a nurse.
What are Nursing Care Plans and Why Do They Matter?
Why learn how to write nursing care plans, evidence based practice papers among other health care paper plans? Nursing care plans are written documents or medical records that form an integral part of the nursing process. Different places may use slightly different formats, but the final document achieves the same aims in every place. Nursing care plans guide how nurses provide nursing care to patients. The documents help nurses working different shifts know the exact actions other nurses have taken for each patient. These records are a consistently reliable way of organizing and communicating the actions of everyone involved in patient care. Specifically, nursing care plans document assessment, diagnoses, planned interventions, and evaluation. Each aspect is a precise process that nurses handle with ease. Once you learn how to write nursing care plans, your confidence will increase. And you’ll likely see better grades.
The 5 Steps That Lead to Well-developed Nursing Care Plans
Nursing care plans do not follow the exact same format in every place. That said, the following five steps should give you a document that satisfies your professor. Here are the steps on how to write nursing care plans: Assessment, Diagnosis, Planning, Implementation/Nursing Orders, and Evaluation. Let’s consider each step and see how each contributes to the final document.
Step 1: Write the Assessment Section of Your Care Plan
While preparing a care plan, assessment is the first step of the process. As you fill out this part of the template, there are a few critical questions you need to answer. Why is the patient here? Why are they seeking care? What’s the patient’s general appearance? You need to be able to do an accurate and comprehensive assessment. Assessment is about collecting and recording different kinds of data.
According to the American Nurses Association, you should gather physiological, economic, sociocultural, and spiritual data. You should also capture lifestyle information. Assessment seeks to understand the physical causes of pain, how the pain manifests itself, and how the patient responds. Your assessment may look like this: Anger directed at family and hospital staff, refusal to eat, request for pain mediation. Maybe your patient’s skin is cold and clammy. The assessment section should be brief, just like every other section included in a well-written nursing care plan.
Step 2: Fill Out the Diagnoses Part of the Care Plan Template
The diagnoses part focuses on the “What” of the patient’s condition. Here, you’re trying to answer this question: “What’s the patient’s problem?” The information recorded in this section helps nurses determine the care the patient will receive. The diagnoses part of a nursing care plan lists the conditions and health problems a patient is facing.It aims to develop a nursing diagnosis statement.
4 Types of Nursing Diagnosis
North American Nursing Diagnosis Organization-International classifies nursing diagnoses into four categories. Here they are: Actual diagnosis, Risk diagnosis, Health Promotion diagnosis, and Syndrome diagnosis. Each type of diagnosis can lead to an effective diagnosis statement, which is the main aim of the diagnosis section. Each diagnosis statement has three parts. The first part is the problem statement or diagnostic label. For example, the problem may be nausea or anxiety. The second part is the “related to” or RT part. This part focuses on the cause of the problem. The third part presents the defining characteristics. Defining characteristics, usually expressed as “…as evidenced by…” means the signs or symptoms that support your diagnosis.
According to NANDA-I, an actual diagnosis makes a clinical judgment about how a patient experiences or responds to health conditions or life processes. Actual diagnoses are existing problems that a nurse can identify. These conditions and life processes may exist in the patient, their family, or community. Here’s an example of an actual nursing diagnosis: Ineffective airway clearance. Or, spiritual distress. Another example: Sleep Deprivation.
A risk diagnosis describes human responses to life processes or health problems that may develop in an individual, family, or community. Here, the family, individual, or community isn’t facing any condition, but they remain vulnerable. Certain risk factors may increase vulnerability for different conditions. Risk diagnoses are health problems, conditions or situations that do not currently exist but which may occur. For example: Risk for shock.
Health Promotion Diagnosis
This diagnosis refers to a clinical judgment regarding the motivation or desire of an individual, family, or community to increase wellbeing. It’s also about the desire or motivation to “actualize human health potential,” according to NANDA-I. That desire or motivation gets expressed as a readiness for specific health behavior(s).NANDA-I further states that a health promotion diagnosis statement normally starts with the phrase “Expresses desire to enhance….” For example: Expresses desire to enhance nutrition.
A syndrome diagnosis is a clinical judgment that describes a particular cluster of nursing diagnoses that normally occur together. Such diagnoses typically get addressed together and require similar interventions. While writing this diagnosis, you must use at least two diagnoses as defining characteristics. For example: relocation stress syndrome.
Here’s how you would write a complete nursing diagnosis statement for your assignment:
Ineffective Airway Clearance: Diagnostic label
Ineffective Airway Clearance RT fatigue: “related to”
Complete statement: Ineffective Airway Clearance RT fatigue as evidenced by dyspnea at rest.
Note: The “related to” and “as evidenced by..” parts are important when you’re writing nursing school assignments. However, they are not always necessary in nursing workplaces where nurses use computers to prepare care plans. One more thing: keep the nursing diagnosis book recommended by your school handy. It promotes accuracy and makes writing diagnoses somewhat easier.
A Nursing Diagnosis is Different than a Medical Diagnosis: Write the Right Diagnosis
Don’t confuse a nursing diagnosis with a medical diagnosis. North American Nursing Diagnosis Organization-International (NANDA-I) clarifies the difference between a nursing diagnosis and a medical diagnosis. According to NANDA-I, a nursing diagnosis describes a patient’s responses to actual health problems or potential health problems. In contrast, a medical diagnosis defines an injury or disease process. Only a doctor can write a medical diagnosis. So, avoid listing down diagnoses such as “Diabetes,” or “Heart disease,” or Cancer.” Based on a nursing diagnosis, a nurse can easily select an effective intervention method.
Step 3: Write the Planning Part of Your Nursing Care Plan
At this point, you need to set specific, measurable, and achievable goals that guide care for the patient. You need to decide what short-range goals and long-range goals the patient’s care will pursue. So, what goals do you want to set for the patient? Suppose you have an immobilized patient. You may set a goal suchasPatient will move from bed to chair 3 times per day. Another goal might be: Patient will tolerate clear liquids within 18 hours without vomiting and nausea. Or, Patient will be pain-free within 3 hours. Let’s write down one more goal: Patient will report decreased nausea within 12 hours. The goals are clear and measurable, and everyone involved knows what each goal means.
Step 4: Complete the Implementation/Interventions Part
The Interventions part focuses on helping the patient and care providers achieve expected outcomes. Each patient’s record reveals the specific actions nurses need to take. So, write down the actual actions that require attention, including how often and how long. For example: Nurse to assess patient’s nausea every 6 hours. Example 2: Nurse will administer pain medication as ordered or needed.
Step 5: Finally, Evaluate the Nursing Care Plan; Decide if the Plan Needs Modification
Nurses must keep evaluating their patients’ wellness or health status. They also need to keep evaluating the effectiveness of the nursing care provided. The evaluation section carefully considers each goal set for the patient. For this section, a goal was either “Met” or “Unmet.” What if a goal gets “unmet?” You may need to revisit the diagnosis step. You may also modify the goals or add interventions.
Nursing Rationales: Not Always Included but Your Professor May Ask You to Include it
Your professor may ask you to include a nursing rationale in your nursing care plan. Nursing rationales can be confusing, and writing them may give you problems. You’ll understand rationales best if you can see how they interact with nursing diagnoses, care goals, and interventions. Basically, a rationale explains why a nurse set a particular goal or chose a specific intervention. Every nursing intervention needs a nursing rationale. Here’s an example of how you might write a nursing rationale:
Pain control will help the patient improve their life by enabling them participate in physical therapy exercises.
Final Remarks on How to Write Nursing Care Plans
Writing nursing care plans can be quite confusing. Nursing students may not always clearly understand the differences between the various elements of a care plan. It’s easy to confuse “Planning” and “interventions,” for example. Also, some students may not know how nursing diagnoses differ from medical diagnoses. One more thing: your instructor decides the specific format you should follow for your nursing assignment. Hopefully, this post has described each part of a nursing care plan clearly and helpfully.
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See video below on nursing care plan tutorial.