How to write Nursing Care Plan

The nursing care plan is a document that is recorded by nurses during patient assessment. The nursing care plan must contain the details of diagnosis, treatment procedure and the intended goal to be achieved, the medication and appointment dates, and a final evaluation plan after the recorded number of days.

Nurses’ core objective is to save lives and help patients manage conditions that are not treatable. They prescribe a care plan for the situation. A nursing care plan also identifies the best treatment procedure, how it should be done, and any risks that could be involved.  This plan varies from diagnosis to diagnosis and there cannot be treated as universal.

Nurses are expected to train the caregivers on how to carry out the plan in the cases in which the patient is to be treated at home. With time-to-time supervision family, members can care for their patients. There are a number of care plans that nurses can subscribe to. Below are some care plans that can be prescribed by nurses and diagnosis or a procedure. Let us now discuss a number of nursing care plans that can be prescribed.

Wondering where to start with writing care plans? Well, a nursing care plan has essential elements like assessment, diagnosis, planning, implementation, and evaluation.

1. Assessment

This is the first stage which involves data collection either from the patient or the caregiver. The nurse is expected to critically think through the questions and answers given.

2. Diagnosis

The nurse’s diagnosis will advise that kind of care to be prescribed.

3. Planning

This is the stage where the goal and outcomes are formulated. The kind of care plan that befits the patient. During this stage, goals that are specific, measurable, achievable, realistic, and time-bound are set for the nurses.

4. Implementation

This is where the formulated care plan is put into action. These could range from injections to the patient being put on oxygen or ventilation. This is the action stage.

5. Evaluation

This is where the nurses evaluate if the action plan was successful or not. They get to know the limitations of the plan and if need be regroup to have another water-tight plan. Nurses can consultatively refer to medical records to have a clear assessment.

Components of nursing care plans

Writing care plans are part of the nurses’ duty to their patients and to the nursing institution. This plan is a part of record keeping for the patient and it encourages continuity even in the absence of the administering nurse. While writing a care plan, there are strict formats and details that nurses must record. Making mistakes during the writing of the care plan can lead to the wrong diagnosis, and wrong prescription and these could lead to the death of the patient.

While writing nursing care plans, nurses should consider the following steps

1. The nurse must assess the patient and be able to analyze the symptoms presented
2. The nurse must come up with a possible diagnosis to be able to explore a better treatment procedure. This could be dependent on the level of seriousness.
3. The nurse must create a rapport with the patient and set goals. This will be informing the nurse what to expect from the care plan prescribed.
4. The nurse must review the progress and be flexible to change the care plan accordingly if the need arises. Nurses must be flexible to change the care plan if the initial set goal is not met.
5. Evaluation of the plan

Writing a care plan could vary from one patient to another depending on the type of diagnosis. Caregivers must also be educated by the nurses on the handling patients like urinary retention patients on catheters amongst others.

Nursing care plans diagnoses interventions and outcomes

The process of assessment, diagnosis, and then evaluation stages are geared towards formulating a preferred care plan. The nurses must evaluate their plan and gauge its success. This allows them to use it as precedence on other decisions while creating a care plan

Nurses are mandated to communicate the diagnosis to the patients and the caregivers. During discharge, nurses prescribe these care plans for conditions that can be managed at home.

Let’s now discuss nursing care plan examples and some considerations nurses must keep while writing a care plan.

Postpartum nursing care plan

Postpartum nursing care is that care plan prescribed by nurses to the new mother although it is dependent on the type of delivery could be normal birth or a C-section birth. It is always a joy for every mum to come out of postpartum healthy.

Postpartum care involves the mother and the infant. The watch is on the baby’s breastfeeding pattern, jaundice check, mother and child attachment care, infection on the c-section area or the episiotomy area, and childbirth trauma to the mother.

1. Normal delivery care plan

Normal delivery is always every woman’s wish because of the limitation of the number of births in the C-section.  Normal birch also has a set of a care plan that the nurses prescribed for the episiotomy like:

1. Warm bath sitting
2. Medication was prescribed after assessing the amount of bleeding

• Usage of postpartum pads

1. Cleaning oneself from the front to the back
2. C section delivery

This is a major procedure to save the mother and the infant.  Some women choose it voluntarily while some are forced by the birth canal not dilating enough to also the passage of the infant.

1. Wound cleaning
2. Infection of the incision area

• Anxiety

1. Headaches from the anesthetic drugs.

Diabetic nursing care plans

Diabetic is a condition where a body is not able to produce enough insulin or utilize the produced ones in the body. As a result, a lot of sugar is stored in the body which eventually causes diabetes.

After the diabetic diagnosis and treatment at the facility, the patient is released under the care of the family members under the instruction of a nurse care plan.

The prescribed care plan are:

1. Dosage administration.
2. Diet administration

• Stress management among others

Psychosocial nursing care plans

Psychosocial patients are a group of patients with mental disorders, those suffering from emotional health, and social, and the effects of chronic diseases such as cancer, and HIV aids among others.

Nurses dealing with such patients are encouraged and given a positive perspective on life. In the plan, the nurses are to assess the self-esteem of the patients and offer training to the caregiver who will be expected to offer emotional, psychological, and financial support to the patient.

Nursing care plans for pneumonia

Pneumonia is an infection of the air sacs. This makes breathing become strenuous for the affected patients. Nurses before setting out a care plan have to understand the history and the infection, diagnose the administer treatment.

In vast cases, nurses are forced to admit patients into the ventilator. Nurses in their care plans have to include teaching the caregivers how to handle the patient while at home and how they should keep the surrounding. In most cases treatment is through medication or ventilation.

Hospice nursing care plans

Hospice care plans are for patients with chronic illnesses. Cancer and tumor are among the illness that requires hospice care plans. Nurses conduct diagnosis and then administer medication.

Hospice care plans would include nursing care plans for depression because the patients’ under such care would easily plunge into depression and other, mental disorders. The home treatment plan must also be given alongside the appointment date. Patients on hospice care plans would also double in the end-of-life nursing care plans. This is for pain management as the patient would sometimes experience excruciating pain. The term end –of –life because that pain and the illness would eventually last a lifetime.

Nursing care plans for atrial fibrillation

Atrial fibrillation is known as an irregular yet very rapid heart rhythm caused by the structure of the heart. When writing a nursing plan the family history must be considered by the nurses as part of the diagnosis as well as nursing care plans for hypertension. A tentative caregiver’s plan and education must be provided for home management through drugs and appointments are booked. Caregivers must also be educated on the danger signs and when to call in. The patients under this care could also be under tia nursing care plans

Nursing care plans for COPD

This is caused by difficulty in breathing. Nurses are to collect data and help the patient reduce anxiety to help regulate the heartbeat then the patient can then be placed on oxygen. An evaluation can then be done on the patient after the care plan is implemented. In the event of discharge, the caregivers must be trained on when to call and how to care for the patient.

Nursing care plan diagnoses

Nurses at the diagnosis stage, employ their clinical judgment in formulating the care to be implemented. The clinical judgment could be derived from the North American Nursing Diagnosis Association (NANDA) which provides nurses with an updated list of diagnoses that could range from severe headaches in the back area, urine retention, edema, liver infection, etc.

During diagnosis, nurses are allowed to use literature referrals. Nurses use a three-phase diagnosis procedure that is: the problem-focused nursing diagnosis which entails the patient’s responses, all the related contributing factors to the diagnosis then the signs and symptoms shown by the patient.

Nursing care plans goals

The goal of a nursing care plan is to help in the documentation of the patient’s needs and the possible outcomes including the nursing intervention and implementations. The care plan is also part o the hospital’s health record as they help in the continuity of the patient’s care

While nurses are preparing the care plan, they are expected to lay down bare minimum guidelines to the plan. The plan must be SMART. The acronym stands for the letter – S – Specific; M – Measurable; A – Attainable; R – Realistic; T – Time-bound.

In a nursing care plan, there are short-term goals and long-term goals.

1. Short-term goal.

A short-term goal in the nursing care plan would be aimed at resolve the situation temporarily. These solutions might not last the patient for a long time. It might only be sustainable for a few days or a few hours depending on the situation. Such short-term goals could be applied to hospice patients.

2. Long-term goal.

These long-term goals in nursing care plans have a longer lifespan and could last for weeks and months. These could be in diabetic patients who could be monitored by caregivers at home. Do you want to write your nursing care plan? Well, check out sample nursing care plans.

Summary

A nursing care plan has 5 major components that are assessment, diagnosis, planning, implementation, and evaluation. Before nurses write a care plan they must think through and draft one depending on the type of diagnosis.

Nurses must set specific, measurable, attainable, realistic, and time-bound goals for the patient’s care plan. These are to be evaluated later after the implementation of the plan. Nurses are allowed to collect data from caregivers or friends during care plan formulation.