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Writing a Nursing Care Plan

Writing a Nursing Care Plan Nursing care plans become second nature as a part of nursing practice with time. A nursing care plan may appear very different depending on the care context and the patient's needs because nursing care planning can be formal or unstructured. While informal care plans may not be documented in the medical chart, developing good formal care plans requires practice. Formal care plans are essential for communicating to the care team significant changes in the patient's condition.   Depending on the electronic health record, computer platform, setting (home health, doctor's office, etc.), and nursing specialization (case management, PACU, etc.), care plans will seem different. Regardless, the nursing process remains constant. Reading samples of high-quality care plans is one strategy to improve your care plan writing skills. Nurses might also solicit comments on their care plans from more experienced colleagues. Some care facilities will have formal care plan templates. Overall, the care plan should flow naturally as part of the nursing process, taking into account important nursing diagnoses, projected outcomes, and the efficacy of planned interventions. Goals are amended as needed, and the care plan is repeated until goals are met or no longer applicable. Rationales Although rationales are not utilized in typical nurse care plans, they are in student care plans. When learning to construct care plans, it can be beneficial to include the reasoning behind the diagnosis and interventions. To guide their understanding, students can describe the pathophysiology underlying their assessment and why their intervention is required.


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