How to Write a Good Care Plan
Part of your responsibilities as a nurse will be writing nursing care plans for your patients. This topic will be covered in school, but also will be very relevant to your day-to-day activities at work. There are multiple formats for nursing care plans that may differ between schools, facilities, and even nurses. In this article, we review basic principles that will help you write a good care plan and an example format that you can use to present this care plan.
Gathering and Using Data
When starting to write your care plan, the first step is to gather all of the relevant information and analyze it. This may include objective data like your head-to-toe assessment of the patient, lab results, vital signs, the patient’s history, and the report from the previous nurse, as well as subjective data like patient complaints of pain and other symptoms. Review this data and prioritize the patient’s problems.
Creating Diagnoses
You will synthesize all of this information to create your nursing diagnosis, which is usually in the form of:
[The problem] related to [the cause of the problem] as evidenced by [symptoms of the problem].
The problem may be a definitive issue, such as “decreased cardiac output” or a risk for an issue, such as “risk for imbalanced fluid volume”. NANDA-I provides resources for creating nursing diagnoses that include approved nursing diagnoses, the related factors for these diagnoses, and the defining characteristics that the nurse may observe.
Setting Goals
The next step is to determine the patient’s goal for this problem. If the problem is pain control, the goal may be that the patient reports a pain level less than 4 for the next 24 hours; if the problem is risk for ineffective airway clearance, the goal may be that the patient does not experience aspiration during the shift. The goals should be specific to the patient and measurable. At the end of the shift or hospitalization, you will evaluate your patient’s progress, so you will need metrics that will allow you to objectively confirm whether the patient has met the goal or not.
Determining Interventions
With your goals in mind, you will now work backward to determine the appropriate interventions that will help the patient achieve these goals. What are the items you or the staff need to do and what are the items the patient or patient’s family need to do? These interventions could include how often the patient will be assessed, activities like dressing changes that may be needed to aid wound healing, and/or additional education to be provided. These interventions will be specific to the patient as they will relate to the patient-specific goals.
Revising the Care Plan
Finally, patients’ conditions change over time or in an instant, so care plans will need to continue to be re-evaluated to ensure that the problems being addressed are the highest priority problems, that the goals are attainable, and that the interventions are appropriate.
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