How to write a nursing care plan?

Writing a nursing care plan requires adequate judgement about the patient’s conditions. A good nursing care plan includes the following steps and techniques.

Step-1:Assessment

Assessment is the first step in writing a nursing care plan. It is a continuous and systematic collection of information and analysis of information. In this nurse gathers all the information like physical assessment, medical and surgical history, social, cultural, economic etc. Nurse not only gathers information from patients but also includes his/her family members. The patient himself/herself can give information or a family member can give information about it. Mostly data was gathered through the interview technique. The nurse can also get the information through observation (Objective method). Some organizations have their own assessment formats. After assessment nurses organise and analyse the whole data.

Step-2: Diagnosis

Nursing diagnosis follows NANDA Diagnosis. It includes client needs, actual and potential problems. Diagnosis not only focuses on the problem but also on causative factors and potential problems.

Step-3: Prioritizing the problems

Prioritizing the problem is very essential. It helps nurses to decide which problem he/she should focus on first. Problems are categorised into high, medium and low. Life risks problems are highly prioritized and should give immediate focus. Maslow’s need chart can be taken into consideration while prioritizing the problem of the patient.

Step-4: Outcomes and goal

Here goals are the destination that nurses want to reach for the patient. Suppose the patient is having a high temperature, the nurse will set the goal as ‘after the intervention patient’s temperature is expected to reduce to 99°F. Usually, goals are of two types i.e. short-term goals and long-term goals. Long-term goals are expected in months and years. Short-term goals are expected within hours to days.

Step-5: Planning

After identifying the problem nurses set goals. After setting the goal nurses plan how to achieve the goal. For e.g., nurses planning to reduce the temperature will plan to give frequent cold sponging, provide light cotton clothes, regular monitoring of temperature, take rigorous precautions etc.

Step-6: Interventions

Things that have been planned are put into action are called interventions. It can be written as For cold sponging of temperature 93°F. Nursing interventions include:

• Assisting with ADL
• Delivering skilled therapeutic interventions
• Monitoring and surveillance of response to care
• Teaching
• Discharge planning
• Supervising and coordinating nursing personnel

Nursing interventions are of three types independent, dependent and collaborative. Nurses can give certain interventions based on their knowledge and skill. They don’t need any order for that. for e.g. giving comfort, basic needs of the patient, emotional support etc. This is called Independent Nursing Intervention. Nurses need verbal or written orders for some interventions, called dependent intervention. For e.g., A nurse needs a doctor’s order before administering diuretics. Sometimes nurses need a collaboration of other health care professionals like the occupational therapist, dietician, psychologist etc., this type of intervention is called collaborative intervention.

Step-7: Rationale

Rationales are the scientific explanations of the nurse’s action. It explains the reason for providing specific interventions. For e.g., A nurse gives cold sponging. Its rationale is heat moves from a higher temperature gradient to a lower temperature gradient through conduction. As a result, it will reduce the temperature of the patient. Mostly it is written by student nurses to understand the reason for providing the interventions.

Step-8: Evaluation

Finally, an evaluation is done to know the result of all the activities. The evaluation result is matched with the goal, to check whether the goal is achieved or not. If not achieved the whole process is repeated with slight modification otherwise terminated. The nursing care plan is one of the important components of nursing activities. It gives a clear pathway to what a nurse is going to do.

Order Now