I recently met a nursing student named, Sarah who had just started on her journey to become a nurse. She was struggling with writing nursing care plans. Sarah struggled with gathering comprehensive patient information, identifying appropriate nursing diagnoses, and formulating effective interventions.
Writing a nursing care plan is an essential skill that every nursing student should master. It serves as a roadmap for providing individualized and effective care to your patients.
In this blog post, you will:
Before we dive into this blog post I know how difficult learning everything in nursing school can be. That is why I am offering you a free nursing mnemonic cheat sheet. Just click below to get your copy!
Alright, lets begin!
A Nursing Care Plan is the way a nurse documents and communicates the Nursing Process.
Nursing care plans are one of the most common assignments in nursing school and can be a valuable resource in the clinical setting. They start when a patient is admitted and document all activities and changes in the patient’s condition. Using a care plan will encourage patient-centered care and make your nursing care more consistent. These plans are also a great communication tool among nurses, other healthcare professionals, patients, and their families.
Nursing students learn to assess a patient, make a nursing diagnosis, create a plan, implement the plan, and evaluate the plan to ensure best practices and outcomes. This process teaches them to problem-solve and make critical decisions. A nursing care plan helps nurses organize their day, know when things need to be accomplished, and balance their workload.
The nursing care plan serves as a communication tool between healthcare professionals, ensuring a coordinated approach to patient care. It guides nurses in delivering evidence-based, patient-centered care, while also promoting continuity of care among different healthcare providers.
Nursing care plans are essential in various healthcare settings, including hospitals, clinics, and long-term care facilities. They facilitate efficient and effective care delivery, enhance patient outcomes, and promote individualized care tailored to each patient's unique needs.
Nursing Care Plans are a written form of The Nursing Process. These plans ensure nurses deliver consistent, patient-centered, and holistic care. Each step in the nursing process is covered in the nursing care plan and helps nurses plan, implement, and evaluate nursing care.
The fives steps in the nursing process are:
Writing a nursing care plan can seem overwhelming, but breaking it down into five simple steps can make the process more manageable. Here are five steps to help you write a nursing care plan:
Gather relevant data about the patient's health status, medical history, current condition, and other pertinent factors. It involves systematically obtaining and organizing information to inform the development of the care plan.
Critically examining and interpreting the collected information and data to identify patterns, relationships, and underlying factors related to the patient's health condition. It involves synthesizing the information to gain a comprehensive understanding of the patient's needs and develop appropriate nursing diagnoses and interventions.
The process of critical thinking and considering various factors and possibilities when developing the plan. It involves evaluating different options, anticipating potential outcomes, and making informed decisions based on the patient's unique needs and circumstances.
The process of converting the collected information, nursing diagnoses, goals, and interventions into clear and actionable language that can be easily understood and implemented by the healthcare team.
The process of accurately documenting the care plan in a written format. It involves transferring the information, including nursing diagnoses, goals, and interventions, into a standardized care plan document or electronic medical record.
Sometimes all you need are a few examples to help you learn how to do a difficult task and to get the brain juices flowing. Here are 3 care plans that I personally wrote during nursing school.
Pathophysiology of Abdominal Pain:
Abdominal pain can be a minor issue that is easy to resolve or a medical emergency. Many different things can cause abdominal pain and their pathophysiology can differ widely. Abdominal pain can is classified as either acute or chronic. When a patient presents to the emergency department or outpatient environment with abdominal pain, it generally constitutes a lengthy workup to determine the cause and its pathophysiology. Additionally, abdominal pain can be referred pain, which can complicate the clinical picture even further.
Etiology of Abdominal Pain
Abdominal pain can be the result of pregnancy, ectopic pregnancy, trauma, a long list of gastric issues (gastroenteritis, constipation, diarrhea, irritable bowel syndrome, GERD, Chron’s disease, appendicitis, to name a few), hernias, allergic response, endometriosis, gallstones, severe menstrual cramps, hepatitis, miscarriage, and many more. Many disease processes result in abdominal pain, and some may present with abdominal pain even though it is not the typical clinical picture.
Desired Outcome
Cease painful stimuli, resolve the underlying cause, and minimize any subsequent damage.
Assessment
Making an individualized assessment of abdominal pain begins by focusing on the available background information of the patient: health history, current health status, psychological state, and other relevant data.
Subjective Data:
Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of abdominal pain, a patient might report feeling:
Objective Data:
Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of abdominal pain, a patient may present with:
Diagnosis
A nursing diagnosis is a basis for establishing and carrying out a nursing care plan. After performing a proper assessment, formulate a nursing diagnosis based on problems associated with abdominal pain. This will be your clinical judgment about the patient’s health conditions or needs.
Select the appropriate nursing diagnostic label from the NANDA-I list of approved nursing diagnostic statements that best identify with the patient’s signs and symptoms. One or more nursing diagnoses may be given.
Planning / Outcomes
Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes.
In the case of abdominal pain, a plan may include:
Implementation
Implementations are actions and activities you will take to achieve the nursing plan goals.
In the case of abdominal pain, an implementation may include:
Evaluation
The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions.
In our abdominal pain example, an evaluation might include:
Pathophysiology of Infection:
An infection is a disease caused by microorganisms infecting tissues.
Etiology of Infection
The organisms that can cause disease are very diverse that include viruses, bacteria, fungi, and parasites. You can acquire such infections by contaminated food/water, a bite, cut, or being in contact with someone with an infection.
Desired Outcome
Patient will remain free from infection and demonstrate proper hand hygiene
Assessment
Subjective Data:
Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of infection, a patient might report feeling:
Objective Data:
Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of infection, a patient may present with:
Diagnosis
Risk for Infection related to compromised skin integrity and invasive procedures.
Planning / Outcomes
Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes.
In the case of infection, a plan may include:
Implementation
Implementations are actions and activities you will take to achieve the nursing plan goals.
In the case of infection, an implementation may include:
Evaluation
The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions.
In infection example, an evaluation might include:
Pathophysiology of Fluid Volume Deficit:
Fluid Volume deficit (dehydration) is a state or condition where the fluid output exceeds the fluid intake. The body loses both water and electrolytes from the ECF in similar proportions. Common sources are the gastrointestinal tract, polyuria, and increased perspiration.
Etiology of Infection
Common causes are decreased fluid intake, bleeding, diarrhea, diuresis, abnormal drainage, increased metabolic rate, movement of fluid into third space, and abnormal losses through the skin, GI tract, or kidneys.
Desired Outcome
Patient has normal vital signs. Demonstrates adequate lifestyle changes to avoid dehydration. Patient has normal urine output
Assessment
Subjective Data:
Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of Fluid Volume Deficit, a patient might report feeling:
Objective Data:
Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of Fluid Volume Deficit, a patient may present with:
Diagnosis for Fluid Volume Deficit
Fluid Volume Deficit related to excessive fluid loss (e.g., vomiting, diarrhea, hemorrhage) as evidenced by decreased urine output, dry mucous membranes, and decreased skin turgor.
Planning / Outcomes for Fluid Volume Deficit
Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes.
In the case of Fluid Volume Deficit, a plan may include:
Implementation for Fluid Volume Deficit
Implementations are actions and activities you will take to achieve the nursing plan goals.
In the case of Fluid Volume Deficit, an implementation may include:
Evaluation for Fluid Volume Deficit
The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions.
In Fluid Volume Deficit example, an evaluation might include:
Mastering the art of writing the perfect nursing care plan is crucial for delivering effective and individualized patient care.
By following the five essential steps -
You can create comprehensive care plans that address the unique needs of each patient.
Remember to utilize evidence-based practice, collaborate with the healthcare team, and continuously evaluate and modify the care plan as needed. With these strategies in place, you can confidently navigate the complexities of care planning, ensuring optimal patient outcomes and promoting the highest standards of nursing practice.
You Can Do This
Happy Nursing!