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

  • Blood pressure

  • Heart rate

  • Respirations

  • Temperature

  • Oxygen Saturation

• Physical complaints

  • Pain

  • Headache

  • Nausea

  • Vomiting

• Body conditions

  • Head-to-toe assessment findings

• Medical history

• Height and weight

• Intake and output

• Patient feelings, concerns, perceptions

• Laboratory data

• Diagnostic testing

  • Echocardiogram

  • X-Ray

  • 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.