Three Steps to writing a Nursing Care Plan

First things first, are you a critical thinker? It is important to utilize critical thinking skills in order to understand and implement good nursing care plans (NCP) either in class or during clinicals. As a nurse, you will sharpen this as you continually practice NCPs so do not worry if you feel weak on this front.

Before we discuss the Three Steps here are ideas to keep in mind prior to writing NCPs;

Create a therapeutic relationship with the patient.  It is important to include the patient when creating NCPs. Their effort is vital in implementing certain interventions.

On teamwork, be inclusive of other health care personell roles. Some Nursing Diagnoses require interventions from others to support nursing care and efficiently achieve set objectives. Commence with the nursing interventions on the NCP in writing and finalize with the other team members roles/activities. e.g counsellors, social workers, physiotherapists etc.

Prioritize the nursing diagnoses in alignment with the urgent assesment findings of the patient. Sometimes you may begin with ¨non risk” and finalize with the ¨risk of¨ diagnoses.


The Three steps;

  1. Data Collection
  2. Analyze the data
  3. Translate

Data Collection;

  • Collect subjective information from interviewing the patient and their accompanying family, patient history, signs and symptoms. These are unquantifiable.
  • Obtain objective information from head to to assessment, Vital signs. These are quantifiable.
  • Others include data from nursing report & patient reviews.

Analyze the data;

  • Understand the pathophysiology & patient history.
  • Group the data collected that relate to each other. Example; Diaphoresis, Tachycardia, patient reports pain on left upper quadrant of 7/10 on the pain scale for 30 mins, patient lying on bed clutching abdomen & groaning…This will direct to a nursing diagnosis of Pain.
  • Within the grouped data indicate either as subjective or objective.

Translate;

  • Assessment;

List the data in groups based on their relationship to each other. This will assist in finding suitable diagnoses. List and write all the possible diagnoses down on a sketch paper.

  • Nursing Diagnosis;

Use the nursing diagnosis manual to find a suitable diagnosis for each group of assessment data.

What is the diagnosis related to? A recent surgery, trauma, or the disease process (pathophysiology).

As Evidenced By; The particular assessed data that you will intervene to resolve.

  • Goals /Objectives;

What you realistically expect to achieve by reversing the specific value you listed under ‘as evidenced by’. By resolving these eventually you’ll manage the nursing diagnosis.

SMART (Specific, Measurable, Achievable, Relevant, Time bound)objectives for how soon the presentation of the patient can improve given the assessment data, diagnosis, and projected interventions.

  • Interventions;

What would you do to resolve the specific ‘evidence’? Visualize nursing activities and/or what other health personnel can do. Since in teamwork, not everything can be done by a nurse, include the role of the physiotherapist, the doctor, social worker, counselor etc. Discuss with them during rounds about your observations and weigh in on how you can work to resolve the particular indicators you noted.

  • Rationale;

The scientific/evidence-based reason behind each intervention.

  • Evaluation;

A measure of the initial assessment data to exhibit the achievement of the set objectives which, in whole, indicate resolution of the particular nursing diagnoses. These are either subjective or objective.


Here is a sample Nursing Care Plan structure for your use.


Share your thoughts on these steps and be sure to give NCPs a shot.

🙂 Cate

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