How to Write a Nursing Care Plan.
When it comes to nursing, it is pretty essential to be able to write nursing care plans in the best of ways. This is an integral part of nursing education and is required for you to be able to give a detailed and in-depth report on the care of the patients. It is also valuable for standardizing the nursing process for both nursing students and professional nurses. Therefore, as a nursing student, you must learn how to write a nursing care plan, which is an important requirement when writing nursing assignments.
What is a Nursing Care Plan?
Nursing care plans are how the nurses document the nursing process for each patient. It is a form of written communication that allows other healthcare professionals to follow through on what is going on with the patient, their diagnosis, the interventions implemented, and the patient’s response to it. This helps maintain the quality of care given to the patient and consistency.
Nursing care plans start when the patient is admitted at the clinic and are a continuous process until the patient is discharged. This thus makes it a vital part of the nursing care process as it is centered around the patient’s individualized needs. It’s, therefore, a good way for the nurses to solve each patient’s needs from a solution-based approach. This is since the nurse has to assess the patient, collect information from them, analyze the data, plan a course of action from the analysis, implement the plan and then evaluate the outcome of the intervention.
Each aspect requires a certain amount of precision from the nurse handling the patient. This makes it vital for you to hone your nursing skills on how to write nursing care plans. Also, for the nursing students to learn the art of how to write a nursing care plan helps them improve when it comes to how to write nursing assignments.
Purposes of writing nursing care plans
The following are some of the main reasons for writing nursing care plans:
- The nursing care plan should clearly outline what is observed on the patient, the patients’ information, diagnosis, interventions, as well as the response and outcome. This should be done properly as it is evidence of care provided.
- Serves as a tool for communication among care givers. When a patient is handed over to a different nurse during a shift change or referred to the following healthcare professional or specialist, this communication is needed to understand the patient’s needs. This ensures continuity of care.
- Ensures individualized care for the patients. This is whereby the nurses are required to analyze the patient’s needs critically and individually and then come up with interventions that are tailor-made only for them
- Serves a tool for reimbursements for the nurses. The insurance requires these records to determine how and what they pay concerning the c are given. This thus emphasizes on the importance of learning how to write nursing care plans.
A nursing care plan can adopt several formats. However, we will look at the five basic steps of writing a nursing care plan in this instance.
Step 1: Assessment Section
The first step in writing a nursing care plan is collecting information on the patient. This is to understand why the patient came to the clinic. You create a patient record with all their knowledge using various assessment techniques. First, gather their physiological data, their economic data, as well as social and spiritual beliefs. You can also capture other information, especially about their lifestyles. You can also observe the patient’s physical manifestations, among other characteristics.
This section seeks to understand the problem the patient is facing, its degree, and how the patient is responding to it. This will be useful in the analysis and diagnosis of the patient. However, it should be brief, concise, and well to the point, as will all other sections of a nursing care plan.
Step 2: Analysis and Diagnosis
After collecting the patient data, we analyze it in this section. This is in a bid to establish what the patient’s problem is, a diagnosis. The information recorded in this part will determine the kind of care the patient receives, making it crucial to write nursing care plans. The nurse will use their clinical judgment to respond to the patient’s response to the assessment at an in-depth level. For instance, if it’s a pain, has the pain caused any other problems, and what is causing it? Does the pain have the potential to cause further complications?
A diagnosis can also be viewed as a problem statement of sorts. This is whereby you make a diagnostic label, the cause of the diagnosis, and then state the defining signs and symptoms as evidence of the diagnosis. This helps define whether the condition is an actual problem, a risk/predisposition problem, health promotion, or a syndrome problem.
Step 3: Planning or Outcome
Using the assessment and the diagnosis, the nurse needs to use this to set some goals. These should be specific, measurable, and attainable goals to act as a guide in caring for the patient. This is a crucial part of writing a nursing care plan because the goals set here determine the evaluation and outcome of the patient’s health. These goals can either be short-range or long-range goals. Short-range goals are for the patient will decrease pain levels within 8 hours. A long-range plan might be Patient will lose 15 pounds in 3 months. These goals are specific, measurable, and attainable.
Step 4: Implementation and intervention
This stage of the nursing plan is aimed at putting into action the goals set in the program. The specific steps for the patients are set in motion. This ensures continuity of care as the instructions are set in the planning stage. The care is therefore documented.
Step 5: Evaluation
This aims to establish the degree to which the goals set in the planning stage are achieved. It is also the stage of looking at the factors that may influence the achievement of this goal. This is to determine whether to continue with the plan, terminate it, or change the course of action.
Providing a rationale
This is a step whereby the nurse is expected to explain why they chose the intervention they did. This step is not used by professional nurses when writing care plans. It is used by nursing students when writing nursing assignments.