How To Write A Nursing Care Plan

Nursing care plans is a formal means of communication among the nurses, their patients, and other healthcare provides to deliver and achieve quality healthcare results. It also involves the identification of existing needs and recognizing the potential needs or risks. Without a comprehensive nursing care plan process, the quality and consistency in delivering quality care would be gone.

Nursing care planning starts once the patient is admitted to a healthcare center and it is constantly updated throughout according to the patient's change in condition and assessment of goal attainment. Therefore, planning and delivering customized or patient-centered care is the basis for excellence in nursing practice.

What is the Purpose of a Nursing Care Plan?

Nursing care plans are part of the core curriculum in almost all nursing schools. However, most nurses often complain that despite the rigorous effort and time spent in learning how to create a nursing care plan, they rarely do it once they are in the nursing profession. But what is the purpose of learning to write a care plan and to what end do they serve?

·         Define a nurse's role: Care plans help in identifying the unique role of nurses in attending the overall health and well-being of patients without having to rely entirely on the doctor’s interventions or orders.

 

·         Guide customized care of the patient: Nursing care plans allow the nurse to think critically about each patient and how to develop interventions that are uniquely tailored to that particular patient.

 

·         Continuity of Care: It allows nurses from different shifts or floors to use the data to render the same quality and kind of interventions to care for patients. This ensures students get the most out of treatment by different nurses.

 

·         Documentation: Nursing care plans outline what nursing actions to execute, which observations to make, and what instructions the patient or loved ones require. If nursing care is not documented in the care plan, then there is no proof that care was provided.

 

·         Define patient goals: Nursing care plans not only benefit nurses but also the patients by involving them in their treatment and care.

 

·         Serves as a guide for assigning a specific nurse to a specific patient: There is a time when a patient's care needs to be assigned to a nurse with specific and precise skills for better handling and care.

For students, there is a need to be taught how to individualize patient care, think critically, and how to work towards attaining the desired outcomes in the nursing process. And knowing how to write nursing care plans is the first step.

How to Write a Nursing Care Plan

 To create an executable care plan, the following steps should be followed:

1.      Assessing the Patient

A good care plan starts by reviewing all the relevant data, medical history, vital signs, conversations with the patient and their loved ones, lab results, observations from other care team members, and demographic information.

With this information, you can assess the patient’s emotional, physical, psychological, spiritual needs, risk factors, and areas for improvement.

2.      Identify and list nursing diagnoses

After an extensive assessment, identify and list nursing diagnoses that you can handle without the physician intervention. This may include acute pain, fever, and risks for falls.

3.      Set goals for the patient

By answering the question, what the desired outcomes are, you will be able to set the goals.  The answer to this question is entirely based on the assessment, nursing diagnosis, and feedback from the patient. Ideally, involve the patient in setting reasonably achievable goals. The goals can either be short-term or long-term.

4.      Implement nursing interventions

These are actions taken by the nurse to attain the desired patient goals and outcome which may include giving medication, checking for vital signs regularly, assessing the patient’s pain levels at specific intervals.  Moreover, this is where you should document care as you execute the interventions, including the dependent nursing interventions as ordered by the doctors.

5.      Evaluate progress and change the care plan accordingly

You can evaluate the patient and the care plans regularly to find out whether the nursing interventions are indeed helping the patient achieve their goals and desired outcomes or should they be changed, modified, continued, or terminated.

Knowing how to write nursing care plans is an important part of your responsibilities as a registered nurse. The key is to be as detailed and precise as possible and use the resources available to help you. Should you need help in writing care plans, Nursing Care Plan Writing Services is readily available to help!