NURSING CARE PLAN
Writing a nursing care plan involves multiple
factors. Developing accurate assessment skills is a
fundamental component of the nursing process
required in order to systematically care for our
patients. Understanding and application of the
nursing process is also a key factor. The nursing
process consists of five critical steps.
1. ASSESSMENT: an organized process
involving 3 basic activities.
a. systematically gathering data using the
head to toe assessment, observational
and communication skills. This
includes subjective as well as objective
data.
b. Sorting and organizing the collected
data.
c. Documentation of the data.
2. DIAGNOSIS: analysis of the collected data in
order to identify the patients needs or
problems and coming up with a nursing
diagnosis within NANDA guidelines.
3. PLANNING: simply put, this is your “plan of
care” or goal. Then your nursing
interventions are chosen. Your interventions
are the actions that you as a nurse are going to
do in order to “reach the selected goal.”
4. IMPLEMENTATION: This requires action.
This is where you ACTUALLY put your
planned interventions into action in order to
meet your goal.
5. EVALUATION: this is where you “assess”
your patients progress toward attaining the
identified outcome or GOAL. The goal is
either met or revised or the interventions
may need to be revised.
Here are some assessment areas that may assist the
nurse in choosing a nursing diagnosis. The findings
from these areas should be documented on your
care plan under presenting signs and symptoms,
notes and observations etc. The more “data” you
have in this area, the easier it will be to come up
with a nursing diagnosis. Some suggested
assessment tools are: activity and rest, circulation,
ego integrity(stress factors,feelings
etc…)Elimination habits (incontinent,diarrhea
etc…)food/fluid intake, hygiene, neurosensory
(tingling,numbness etc…) pain/discomfort,
respiration(SOB,dyspnea etc…) safety, social
interactions and teaching/learning needs. These are
a few suggestions to assist the nurse in developing
a nursing care plan for the patient. By looking at
these areas, the nurse will be able to come up with
a plan of action in order to care for the patient.
Remember…the more observations you make of your
patient, the easier it will be to find an appropriate
nursing diagnosis. Also remember to include
subjective as well as objective data. Always put
your care plan in your “OWN” words. Make use of
all resources such as your Foundations of Nursing
book, Adult Health, Nurses Pocket Guide and the
internet. These are but a few suggestions to assist
you in the development of your care plan. Keep it
simple and make use of your developing assessment
skills!!! This is but a beginning!!!!
The nursing care plan that you are going to create
has multiple components. The first area is your
diagnosis. You will be forming your diagnosis from
your assessment. The diagnosis must be NANDA
approved and patient centered. After assessing
your patient you will have a “list” of abnormal
data that will help you with your diagnosis. You
will be identifying a problem that you as a nurse
can do something about, that is you can either
make the problem better, or solve it or prevent it
from worsening. The diagnosis will include certain
information such as… what it is related to (why
the pt. has the problem) and what it is evidenced
by ( what you see that led you to believe the pt. has
the problem) Next you will list objective data.
Your objective data is what you “saw” that led you
to the diagnosis or problem. Your objective data
will come from your assessment findings and will
also include the “evidence” of the problem. Next is
the subjective data. This will be anything that the
pt. states that relates to the problem. If the pt. does
not contribute to this area, you may write “pt. did
not contribute.” Now comes the “tricky” part.
Your goal!!! The goal is going to be what you want
accomplished regarding the diagnosis/problem.
That is…what do you want to do about the
diagnosis/problem. Your goal must be SMART!!!
S=specific, M=measurable, A=attainable, R=realistic
and T=timely. When coming up with your goal, you
must consider all of these.
The next area of your care plan is your
interventions. Interventions are the things that
you are going to do in order to meet your goal. You
must have at least 4 interventions. Remember, your
interventions are the actions that you are going to
take to meet the goal. Along with your
interventions are the rationales. These are the
reasons why you are doing your interventions.
Basically the rationales explain what the purpose
of the interventions are.
The final area of your care plan is the evaluation.
Was the goal met or do you need more time. Do you
need to reconsider the goal?
Care plans are an integral part of what we do as
nurses. The internet offers a vast amount of
resources as do your books from school such as
your Adult Health and Foundations of Nursing.
Your pathophysiologies can help you with your
care plans as well. Your pathophysiologies are a
report about one of your pts. diagnosis where you
will learn signs and symptoms, treatment and
nursing interventions. Remember this while you
are doing your care plans. In term 2 we are only
introducing care plans. We want you to understand
the basic concept of a care plan and how to begin to
formulate it. Keep it simple at first until you have a
better “grasp” on the whole idea. Remember…the
instructors are here to help you . If you are having
difficulty with this or anything else for the matter,
PLEASE let us know!!! If you don’t know
something…ASK!!!! The more you work on your
care plans, the better understanding you will
develop. The “light bulb will come on !!!!!”