How to Write a Nursing Care Plan
- March 16, 2022
- Posted by: admin
- Category: Nursing Care Plans
You cannot avoid care plans in nursing school or the workplace if you are a nurse student or nurse professional. Nurse students learn the process of writing nursing care plans in detail during nursing school. It is for this reason that your instructor asks you to write care plans often. Writing nursing care plans is a requirement for anyone in mental health or community care. Any student who aspires to become a professional nurse needs to learn how to write nursing care plans.
Why is Nursing Care Plans Important?
The nursing care plan is a written document or medical record that plays a significant role in the nursing process. While different locations use different formats, the final documents have the same goal regardless of where they are used.
In essence, nursing care plans are intended to guide nurses on how they provide patient care. Nurses working in shifts can know exactly what other nurses have done for each patient because of them. Consequently, these records constitute a reliable method for organizing and communicating the various patient care actions of each health care practitioner.
Nurses document assessments, diagnoses, planned interventions, and evaluations through nursing care plans. Nursing care plans are accurate processes that nurses must handle with ease and care. Consequently, once you become proficient in writing nursing care plans, your confidence in nursing will increase, and you will attain better grades.
Steps to Writing Exceptional Nursing Care Plans
Different nursing care plans follow different writing processes due to their different formats. However, you can use the following five steps as a guide to writing a nursing care plan that will impress your professor.
First step: Assessment
An assessment is the beginning of the process of writing a nursing care plan. In this section, you need to answer a few critical questions. Some of these questions are;
- What is the purpose of the patient’s visit?
- What is the patient’s reason for seeking care?
- How does the patient look in general?
The following questions will allow you to obtain an accurate and complete assessment of the patient’s health. You will gather and record different information about the patient during this assessment. It is extremely important to capture information regarding the physical, sociocultural, economic, lifestyle, and spiritual dimensions of the patient. Furthermore, the assessment aims to determine the physical causes of pain, how the pain manifests, and how the patient responds.
The second step is the diagnosis
In the diagnosis section, we seek to understand “What” the patient’s condition is. As a result, you will attempt to answer the question: what is the patient’s problem? As you record the diagnosis, the nurses will be able to determine what kind of care the patient will receive. There is a section in the care plan which asks for a list of conditions and health problems a patient faces.
The third step is to plan
To guide care for your patient, you need to set specific, measurable, and attainable goals. It is possible to set both short-term and long-term goals that the patient will follow. For instance, if you have an immobilized patient, what goals can you set? You may set a goal such as: “The patient will move from bed to chair 3 times per day.”.
The fourth step is implementation and interventions
The implementation or intervention part is designed to assist the patient and caregiver to achieve the desired results or outcomes. Nurses will be required to follow specific instructions in each patient’s record. As a result, list the actual actions that require attention, as well as the frequency and duration for each. The nurse should check the patient’s nausea every five hours, for example. An order or need for pain-relieving medication may be handled by a nurse.
The fifth step is to evaluate
In this section, the nursing care plan is evaluated to determine if it needs to be modified. By assessing the patient’s wellbeing or health conditions, this can be accomplished. This can also be achieved by continuously evaluating the quality of nursing care provided to patients. Evaluations should include evaluating the effectiveness of all patient goals. Assigning a goal status of “Met” or “Unmet” is possible.
When a goal isn’t achieved, what happens? If this is the case, you may have to go back to the diagnosis step to determine an accurate diagnosis. Additionally, you may want to modify the goals or add more interventions.
Rationales for nursing
In nursing care plans, nursing rationales are not always included. You may be asked by your professor to include a nursing rationale in your nursing care plan. Many nursing students struggle with nursing rationales and writing a good one is challenging. If you can see the interactions between nursing diagnoses, goals, and interventions, you can easily understand nursing rationales.
In essence, a rationale is a reason why a nurse sets a specific goal or chose a particular intervention. Therefore, every nursing intervention should have a rationale behind it. As an example, pain management will allow patients to do physical therapy exercises, which will improve their quality of life.
Whether you are a nursing student or a professional, writing nursing care plans is no doubt challenging. Especially if they cannot distinguish between the different components of a care plan, nursing students may have difficulty understanding it. It is easy for them to confuse the portions of the care plan dealing with planning and intervention. It may be difficult for others to distinguish between nursing diagnoses and medical diagnoses.
For students, nursing care plan writing services are available for professional assistance if they are stuck with their nursing care plans. When you hire nursing care plan writing services, you are guaranteed a customized care plan tailored to the needs of the patient that includes a detailed plan of interventions and actions that will enable the patient to achieve the projected goals.
Additionally, our experienced writers will professionally guide you on how to write nursing care plans for various diagnoses to ensure you get the grades you need to graduate. All of these things put you in a strong position to handle any nursing care plan that comes your way!