To be a successful nursing student or nurse you must understand how to write nursing care plans. Studies by ANA have shown that nursing school students who can write kick-ass nursing care plans proceed to have successful careers in the nursing workplaces. So now that your professor insists that you must know how to write nursing care plans or how to write nursing diagnosis, do you have any choice? Probably no!
It is always never just about writing but writing detailed nursing care plans. Learning the steps on how to write a diagnosis makes you think like a professional nurse. So every time you get a chance to write nursing assignments, do not frown. It is the best training you are getting. And when you master the art of writing nursing care plans, whether when studying or practicing in clinical settings, you can work in community care and mental health care centers.
Now, in this piece of nursing pearl, we take you through the steps of mastery on how to write nursing care plans. We believe that the sooner you love nursing care plans, the easier it is for your academic and career progress.
We do not want you asking what a nursing care plan is the last moment. We want you to have access to nursing care examples, write a nursing diagnosis, and learn how to do a nursing care plan. That is what this entire article is about. So, grab some pen and paper, and most importantly a glass of water or coffee, because it is about to get real.
As a professional nurse and an educator, it will be a disservice to assume you know the answer to the question “what is a nursing care plan?” By the way, why do we need to learn how to write a nursing care plan?
Now, nursing has evolved to be evidence-based and that is why you will be assigned to write evidence-based practice papers. Writing the best nursing care plan is an unavoidable skill and requires a stepwise approach.
Nursing Care Plans abbreviated as NCP are formally written documents or medical records that are very critical in the nursing diagnosis process. Nursing care plans document the assessment, diagnosis, interventions, and evaluation of patients. Specifically, nursing care plan records the identification of existing needs, recognition of the potential patient needs, and potential risks.
The nursing care plans help nurses to plan how to offer nursing care to patients. Even when taking different shifts, nurses can offer consistent and continuous care to patients. Still, the care plans help nurses to communicate with multidisciplinary teams on matters pertaining to patient care.
With the knowledge of writing nursing care plans, your confidence in handling a patient increases. Do you know that offering individualized or patient-centered care depends on how good your nursing care plan is? Well, now you know!
There are two major types of nursing care plans:
Before learning how to write a nursing diagnosis, it is paramount to understand the formats or types of nursing assignments. Care plans can either be formal or informal.
The formal nursing care plans are in print, written form, or computer-generated guides that organize the information vital for the care of patients. Formal standardized care plans are specific to the daily nursing care needs of given groups of clients or patients. On the other hand, the individualized care plans are specifically written to suit the unique needs of specific patients that cannot be addressed in the former.
Nursing care plans have different objectives and goals.
These are but a few uses of nursing care plans. But how do we write nursing care plans?
Each workplace has a different nursing care plan format. You must understand that care plans are not an excuse for nurses to be busy. In light of this, there are 5 critical steps of writing nursing care plans. The steps include:
You must acquaint yourself with the NANDA nursing diagnosis samples either as a student or a professional nurse.
The first step in writing a nursing care plan is data collection or assessment. It is critical to have a client database developed using data collection methods and assessment techniques. The data collection methods include physical assessment, interviews, review of medical records, diagnostic studies, health history of the patients.
Having a small database or medical record of the patient helps organize all health information that is gathered. When doing this part, you should focus on related risk factors and the important facts that can be used in formulating a nursing diagnosis.
Your professor can provide the nursing assessment format or form and all you need to do is fill. If not there are several nursing assessment examples online.
Now, you have to ask yourself these questions:
You would agree with the American Nursing Association that when gathering patient data your focus should be economic, physical, emotional, spiritual, sociocultural, and physiological data. Understand the lifestyle of the patient and the source and the manifestation of pain.
With a greatly written assessment section, you are sure that you have a good nursing care plan.
A nursing care assessment section if succeeded by the diagnosis part. This part lists the health problems and conditions of the patients with the aim of formulating a diagnosis for the patient. Again, to succeed in this part you must acquaint yourself with the North American Nursing Diagnosis Organization (NANDA). Still, it is paramount to understand the types of nursing diagnoses.
Studies have proven the efficiency of nursing care plans based on NANDA in improving skills on the choice of diagnosis, formulation of diagnosis, and individualization of care.
NANDA International refers to a nursing professional organization that develops researches, refines nomenclature, criteria, and taxonomy, and disseminates nursing diagnoses.
According to NANDA, there are four types of nursing diagnosis: Acute diagnosis, risk diagnosis, health promotion diagnosis, and syndrome diagnosis. Stick to the best format to ensure that you are writing the best diagnosis statement and for a better diagnosis nomination.
Diagnosis begins with a diagnostic label also known as a problem statement. The second section is the RT or related part that highlights the cause of the problem. The third, and the last, part focuses on the defining characteristics which are based on inferences based on the signs and symptoms.
After writing the nursing diagnosis (NDx), you need to plan for the appropriate nursing care for your patient. It entails the setting of SMART goals to guide the care for the patient.
It involves writing the desired outcomes or goals the nurse hopes to achieve after implementing the various nursing interventions and tie with the nursing diagnosis of the patients. The goals can either be short-term or long-term. Long-term goals are objectives intended to be achieved over a long period, either months or weeks. On the other hand, short-term goals are based on behavior or health patterns depending on short times including days or a few hours.
Planning also entails discharge planning where the long-term goals are states to promote restorative care and problem-solving at home or after discharge.
It is in this section that you highlight or set priorities of care which outlines the sequence to execute and address the nursing diagnosis and intervention.
Here is a sample nursing goal statement or plan: The patient will be free of pain within 12 hours or the patient will be covered using blankets to restore normal body temperature in 5 hours.
After writing the planning section of the nursing care plans, the next part is to draft the best nursing intervention. Interventions are meant to help achieve the goals of the patients/clients.
Mostly, interventions seek to reduce or eliminate the etiology of the nursing diagnosis. With risk nursing diagnosis, the interventions should reduce the risk-factor exposure of the patient. Therefore, the nursing interventions must come up during the planning step of any nursing process. However, the implementation only becomes potent during the implementation phase.
There are different types of nursing interventions:
Interventions must be achievable given the resources and time. Besides, they should align with the culture, values, beliefs, and preferences as well as therapies the client is undertaking. Ensure that the interventions are also evidence-based.
So, when writing an intervention, there must be a data and signature of the nurse. The interventions should be specific and precise and abbreviations only accepted by an institution should be used.
Even though your professor or instructor might not ask for this, but writing a scientific explanation of the basis of an intervention is preferred in a nursing care plan.
The main aim of the rationale is to assist the nursing students to link different psychological and pathophysiological principles to the nursing interventions.
With a nursing care plan that has a rationale for the intervention, your professor will praise you for having a well-written nursing care plan.
A nursing plan care evaluation plan helps you offer ongoing and purposeful follow-up of the progress of the patients towards the achievement of the set goals.
It helps define the effectiveness of the nursing care plan and helps draw conclusions to determine if an intervention is effective or should be changed.
Note: Nursing Care Plans follow hospital policies and they eventually become the permanent medical record of the patients. You must also understand that diversity in programs makes nursing care plan formats different. Most of the NCPs follow the five-column format while others allow students to systematically record interrelated steps.
For sample nursing care plans and NANDA nursing diagnoses, visit the Nursing Labs Website for more information. However, for help with writing a nursing care plan, our nursing care plan writing service comes in handy.
For nursing care plan templates and nursing plan examples, check online.
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