How to write a comprehensive Nursing care plan

If you are a nursing student, one of the things you will be required to write is a nursing care plan. Students are required to write these plans to assess their ability to process critical patient information and think professionally. To be able to write an exemplary nursing care plan, you need to adopt a step-by-step approach. This ensures that you can correctly complete and fill the sections that make up a care plan. Here is everything you need to know about that.  

What is a nursing care plan?

A nursing care plan (NCP) is a formal process that involves accurately identifying existing needs and recognizing potential risks. A care plan is a formal communication between nurses, patients, and other healthcare workers that helps achieve positive healthcare outcomes. A nursing care plan ensures that consistency and quality in patient care are maintained.

Nursing care planning starts as soon as a patient is admitted to a facility. The plan is updated based on the changes in the condition and goals achievement evaluation. A nursing care plan is a roadmap to how a nurse provides care to patients. These are reliable ways of communication amongst everyone involved in the care of a patient.

Generally, a nursing care plan documents diagnoses, planned medical interventions, and evaluation of a patient.

Types of nursing care plans

Nursing care plans can be either formal or informal.

An informal care plan is an action strategy existing in a nurse’s mind. Once this plan is put down on paper and computerized, it turns into a formal care plan.

Formal care plans are sub-divided into individualized care plans and standardized care plans. The latter is specific to offering care to a group of patients with everyday needs, while the former is tailored to meet the specific needs of a patient that are not addressed in standardized care plans.

The goals and objectives of writing a nursing care plan

• Promote evidence-based nursing care and offer familiar and pleasant conditions in health centers and hospitals.


• To support holistic patient care that involves physical, social, psychological, and spiritual care in relation to the prevention and management of a disease.


• To establish programs like care bundles and care pathways. Care bundles are related to the best nursing practice concerning the care provides for a specific illness. Care pathways involve a team effort to reach a consensus about the standard of care and expected results.


• To identify and distinguish expected outcomes and goals.


• To measure nursing care.


• Review documentation and communication of the care plan.

The purpose of a nursing care plan

Defining a nurse's role – a nursing care plan helps identify the unique role a nurse plays in a patient's overall well-being. This ensures they do not rely solely on doctor’s orders and interventions.

Providing a framework for individualized patient care – a nursing care plan allows a nurse to think critically about each patient's case to develop tailored interventions specific to the patient’s needs.

Continuity of health care – the data saved on a care plan can be referred to by nurses in different shifts to ensure the same quality of care is extended to0 the patient at all times. This ensures patients enjoy the maximum benefits of their treatment.

Documentation – a nurse care plan should accurately outline the type of observations a patient needs and the nursing actions to be undertaken. It also shows the instructions required for the nurse and the family members to the patient. A nursing care plan is evidence of care provided to a client.

It is a special care guide – a nurse care plan serves as a guide for special patient needs. It is used to tell when a patient needs to be attended to by a specialist. It is also used as an important document for insurance companies that can be used to determine what they cover in relation to the care accorded to a patient.

The steps to writing the best nursing care plan

While nursing plans can be written in many formats, the writing process is usually done following specific steps. These steps include assessment, diagnosis, planning, implementation, and evaluation.

Assessment

This is the first step to writing a nursing care plan. Without an assessment section in a care plan, it would be impossible to formulate a patient care plan since you will have no information about them. When filling out the care plan assessment, you need to answer certain questions like why the patient is there, why they seek health care and their general appearance. It is important to conduct an accurate and comprehensive assessment of a patient to be able to have the material to fill this section.

According to different Nurses Associations, your assessment should cover information about the patient’s economic, psychological, spiritual, and sociocultural information. The assessment should seek to explain the physical causes of the condition, how the symptoms manifest, and how the patient’s body responds.

An example of an assessment can be: ‘patient directs anger towards family members, refusal to eat, need for pain management medication.’ Ensure you keep the assessment section brief but detailed.

Diagnosis

This is the part of the nursing care plan that focuses on the ‘what’ of the condition. In this section, you should answer the question, ‘what is the patient’s problem?’ the information recorded in the diagnosis section helps nurses determine the patient's care. The diagnosis should list the health complications a patient is facing and helps to develop a diagnosis statement.

There are 4 categories for diagnosis:

Actual diagnosis

This type of diagnosis makes a clinical judgment of the patient’s experience and response to a health condition. Actual diagnoses are the health problems that a nurse can identify. These can be conditions that exist in a patient, a community, or a family. For example, an actual diagnosis can be ‘ineffective airway clearance, sleep deprivation, or mental distress.’

Risk diagnosis

This type of diagnosis describes a patient’s response to health problems or life processes common in the patient, community, or family. In this diagnosis, the family and community do not face any conditions, but they remain vulnerable, with certain risk factors increasing vulnerability. Risk diagnosis is a health situation that does not currently exist but has the potential to occur.

Health promotion diagnosis

This diagnosis refers to a clinical assessment concerning an individual, community, or family’s willingness to boost overall wellbeing. It also refers to the motivation or desire to reach human health potential. This desire and motivation are expressed as a willingness to adapt to specific health behaviors. A health promotion diagnosis usually starts with the words ‘express desire to enhance…’ like ‘express desire to enhance nutrition.’

Syndrome diagnosis

This is a clinical judgment used to describe a cluster of diagnoses that occur together. These types of diagnoses are address together since they require the same kind of interventions. While writing a syndrome diagnosis, you must use two diagnoses as the defining characteristics.

Planning

This is the part of the nursing care plan where you are expected to set measurable, specific, and achievable goals that act as a framework for a patient’s care. This part of the care plan should outline both short-term and long-term goals regarding the care the patient will receive.

For example, if you are attending an immobilized patient, your goals can include allowing the patient to move from the bed to a chair a few times a day. Another goal can be helping the patient to be able to retain clear liquid for a specific amount of time without nausea or vomiting. You can also set a goal to ensure a patient is pain-free for a few hours.

Implementation/intervention

This part of the nursing care plan ensures the nurse and patient achieve the expected outcome. Each record should specify the actions the nurse needs to take to achieve the preset goals. You should write down the actions that need attention, including the frequency of these actions and the amount of time the patient needs to undertake. For instance, an intervention action can remind a nurse to assess a patient’s nausea every 6 hours or redeem pain medications as ordered.

Evaluation

This is the last step to writing a nursing care plan, and it is used to ensure the plan is modified as needed. An evaluation process involves checking the process of the patient and evaluating the effectiveness of the care provided. The evaluation sections in a nursing care plan carefully consider the goals set for each patient and assess whether the goal was met or unmet.

If a goal is unmet, there may be a need to revise the diagnosis steps and modify the goals and intervention type.

A nurse’s rationale

This is usually the last part of a nursing care plan. It can be included in your care plan if your professor insists on it. A rationale is meant to explain the reason for setting specific goals and choosing a particular intervention method. In the medical field, it is always important for a nursing care plan to include a nursing rationale.

An example can be that pain control can help the patient by improving their quality of life and enabling them to participate in therapy activities.

Conclusion

Writing a nursing care plan can be one of the most confusing writings in the nursing field. With this guide, you will be able to create an acceptable nursing care plan while ensuring you understand the components of this writing at a deeper level. Ensure you stick to the instructions highlighted in the assignment, and that you format your plan accordingly.

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