Nursing Care Plan: What You Need to Know
A nursing care plan is essential to student nurses and nurses alike. It is the basis of patient care and helps understand the patient’s condition. How can you write an effective nursing care plan?
What is a Nursing Care Plan?
A nursing care plan is a plan that contains relevant information about the patient’s diagnosis, goals of the treatment, and specific nursing orders. It also contains the evaluation plan and actions that must be performed on the patient.
The nursing care plan is also updated throughout the patient’s stay—any changes in the patient or if there’s new information added to the plan. In some hospitals, nurses must update their care plan during and after the shift to see improvements.
The nursing care plan aims to help define a specific patient’s nursing guidelines and treatment. It is a plan that helps guide nurses throughout their shift in caring for their patients. It also allows nurses to give their patients focused and attentive care.
What Makes up a Nursing Care Plan?
There are several components used in a care plan. These include the following:
- Nursing Diagnosis – this is a clinical judgment that helps nurses develop a care plan for their patients.
- Expected outcome – is a measurable action plan for a patient to achieve within a specific time frame.
- Nursing interventions and rationales – are actions to be taken to achieve the expected outcomes and reasons behind them.
- Evaluation – is how you determine the effectiveness of the care plan and see if the expected outcomes are met within the said time frame.
These components are essential to the overall nursing care plan and process. A good nursing care plan must have these sections, or it will not make sense:
4 Types of Nursing Care Plans
There are many ways to write a care plan. Memorizing how they help you is essential. Here are the four types:
- Informal – is a care plan that exists in the nurse’s mind. The action plan for this care plan is what the nurse wishes to accomplish during their shift.
- Formal – a type of care plan that is written or computerized. It is organized and coordinates with the patient’s care information and plan.
- Standardized – is nursing care for a group of patients with the same everyday needs.
- Individualized – is a care plan tailored to a specific patient’s needs.
How to Write a Nursing Care Plan
One of the first things you need to determine before writing a nursing care plan is to see the problems affecting the patient. What are the medical problems that affect them? Not just the medical problems but the psychosocial problems as well.
Once you have listed the problems affecting the patient and the corresponding nursing diagnosis, you can determine the essential ones. Consider the ABCs or the Airway, Breathing, and Circulation to determine this. However, these will not always be the basis or be relevant to your patients.
Step 1 – Assessment
To determine your care plan, always assess your patients first. It means you must gather subjective and objective data from your patients.
Subjective data is what the patient has verbalized. It could be symptoms, feelings, perceptions, and even their concerns.
Objective data is the information you’ve gathered based on observation. These are often measurable and can come from:
- Vital signs – blood pressure, respiratory rate, heart rate
- Verbal statements of the patients and their family
- Physical complaints – for example, headache, pain, nausea, vomiting
- Body conditions – assessing the patient from head to toe
- Medical history
- Height and weight
- Intake and output
- Patient feelings, concerns, perceptions
- Laboratory data
- Diagnostic testing – like X-ray, EKG, echocardiogram etc.
Step 2 – Diagnosis
A nursing diagnosis best fits the patient’s condition, objectives, and goals for the individual’s hospitalization.
The North American Nursing Diagnosis Association or NANDA, “a nursing diagnosis is 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.”
Nurses can also formulate a diagnosis based on Maslow’s Hierarchy of Needs. With this, nurses can formulate a treatment plan and prioritize them. It also helps determine their next step.
Types of Nursing Diagnosis
There are four types of nursing diagnoses that you can do. These are:
- Problem-focused – the diagnosis is based on the problem present in the patient.
- Risk – includes the risk factors nurses see that require intervention from them and the healthcare team before a real problem develops.
- Health promotion – aims to improve the general well-being of the patient, their families, and/or community.
- Syndrome – occurs in a pattern or can be addressed through the same nursing interventions.
Once the nurses determine the diagnoses, they can begin their nursing diagnosis statement. There are three main components of a nursing diagnosis. These are:
- Problem and its definition – refers to the patient’s current health problem and the nursing interventions needed.
- Risk Factors or etiology – are the possible reasons behind the problem or the contributing factors that led to the patient’s condition.
- Defining characteristics – are the signs and symptoms that allow the specific diagnostic label in the place of defining characteristics for risk nursing diagnosis.
Step 3 – Outcomes and Planning
Once you have your nursing diagnosis, create a SMART goal based on evidence-based practices. SMART goals are:
It is also best to consider the medical diagnosis of the patient and overall condition for your data collection. Consider the goals you want to achieve for this patient and the short- or long-term outcome. It should be realistic and something the patient wants to do.
Step 4 – Implementation
After setting all the goals, implement them to help your patient achieve them. Some actions will have immediate results; others may be seen later during hospitalization. During the implementation phase, you will be performing your nursing care plan.
Your care plan must include the patient’s family, behavioral and physiological aspects, community, safety, health system interventions, and complex physiology.
Some interventions implemented are diagnosis or patient-specific, but several can be completed within a shift. These are:
- Pain assessment
- Position changes
- Fall prevention
- Providing cluster care
- Infection control
Step 5 – Evaluation
The last part of your nursing care plan is the evaluation phase. It is where you evaluate the outcome of your care plan and see if the goals are met during the shift. The possible outcomes are met, ongoing, or not met.
The evaluation can determine if the goals and interventions need improvement. Ideally, these goals must be met by the time of discharge.
However, it is not always the case, especially if the patient is discharged to home care, hospice, or long-term care facility. The outcome of your goals always depends on the patient’s condition.
It would be best to choose achievable nursing goals that the patient can do. It will also help the patient feel that they have accomplished something and are progressing toward recovery.
Nursing care plans are essential in patient care. They are your guidelines for your patient’s progress. You must learn to write one and implement your care plan each shift. It will help you polish your nursing skills as you learn how to care for your patient.
Hopefully, this post helped you; good luck!
Looking for more student resources? Check out these helpful links!
- Spotify Nursing Student Playlist: https://open.spotify.com/playlist/2zGnOjxOhMKDVIEnecJTSl?si=c046eca38aad4775&nd=1
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- NCLEX Study guide: https://cupofnurses.com/nclex-study-guide/
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- Nursing Cheat Sheets: https://cupofnurses.com/resource-page/
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