How to write a Nursing Care Plan

In line with achieving the best patient outcomes and streamlining the work of nurses in a healthcare institution, coming up with a formal nursing care plan is a vital element in the provision of quality health care.

This article will offer a comprehensive guide into understanding what a nursing care plan is, why every hospital, as well as healthcare providers, will benefit from it, the components of a care plan, the necessary details of an NCP, the implementation process of an NCP and how to write a nursing care plan.

So What is a Nursing Care Plan?

In order to achieve the best patient outcomes that put the patient at the center, registered nurses are required to follow a systematic process that puts into focus the needs or by assessing risks of a particular situation and how to handle them. This process is known as a nursing care plan.

Care plans enhance quality communication between nurses, patients, and other care team members. By doing this, quality care and consistency are guaranteed across the healthcare setup.

What is The Importance of a Nursing Care plan in A Hospital?

Nursing care plans play an important role on the patients, the nurses, and the hospital institution in general in the following ways

  • Individualized and patient-centered care. Nurses are able to apply critical thinking and the use of evidence-based care for each individual patient to come up with nursing interventions that are tailored for the unique needs of each client.
  • Enhanced collaboration among the nursing staff. Due to the effective communication protocols across the nursing staff and the hospital unit, a partnership is enhanced through the sharing of information and opinions. This, in turn, enhances the quality of care that the patients receive.
  • Clearly defined nurses’ roles. To make work easier and to avoid overreliance on the physicians to direct nurses on what to do, the nursing care plan offers a comprehensive guide for the nurses to be aware of what their duties are.
  • Proper documentation and compliance with protocols. Properly detailing the step-by-step procedures and guidelines, patients, as well as other stakeholders, are assured that the highest standard of care has been offered.
  • Defines patients’ goals. Each patient has unique needs and the care plans set the target and outcomes to be achieved for each patient.
  • Guide for remuneration. Third-party agencies such as insurance companies go through the patients’ medical records to ascertain care given, for them to process the payment claims of the health institution.
  • Continuity of care. When switching between different shifts, it is important the nurse hands over the data for the patient to the incoming shift. This ensures that the same treatment quality is extended across the shifts.

    The components of a Nursing care Plan

A nursing care plan has 5 basic components that guide the process of coming up with a nursing process. They are

Patient Assessment.

In order to come up with a holistic care plan for patients, the first step is data collection. This process employs critical thinking skills to assess patients’ needs. Data is collected from the medical results medical diagnosis reports.

Some of the data for the patient assessment comes from questions or observations revolving around the following areas; sexual activity, age, emotional, physical and mental ability, and cognitive and functional abilities. The information gathered can be either subjective( verbal cues) or objective(for example weight measurement) or both.

Nursing Diagnosis

After data has been collected, the next step is to come up with a diagnosis for the patient. NANDA (Nursing Diagnosis Association) describes a medical diagnosis as an individual, family, group, or community’s clinical judgment about the human response to health conditions or life processes, or vulnerability to that response.

In line with the diagnosis arrived at after thorough assessment, a list of desired goals and outcomes is formulated.

 

Outline of Desired Outcomes

These are the goals that seek to be achieved after a nursing intervention has taken place. Depending on the diagnosis they can either be short-term or long-term goals.

Implementation

In line with evidence-based care guidelines, the registered nurse implements the planned nursing interventions practices as per the doctors’ orders or as personally developed by the nurses following stipulations of the informed care guidelines.

 

Evaluation

This is the final step where the doctor or the nurse documents whether the outcomes have been achieved or not. This is done by monitoring the patient’s progress throughout the entire duration and making adjustments and changes where necessary.

Formats for Nursing Care Plans

Different institutions employ the use of different formats of a nursing care plan depending on their needs and preferences. The two most common formats are

The Four-column Format

This format divides the plan into four columns that each have these headings on each column respectively; (1) nursing diagnosis, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation.

The Three-column Format

Unlike the four columns format where the outcomes and evaluation are in separate columns, in the three-column format, the outcomes and evaluations sections are combined into the same column so that you have a plan that has column headings looking like this (1 ) Nursing diagnosis (2) outcomes and evaluations and (3) Interventions.

 

An Effective Nursing Care Plan Should,

Communicate Clearly

Great writing skills come in handy when writing a care plan. it is important that the NCP have accurate descriptions so that it offers clear communication across all the stakeholders. some of the important pointers when writing an NCP are ;

  • Write immediately to avoid forgetting
  • Include date and time
  • Use clear and concise terms that all the team members will understand.

Be Up to Date

For quality care of the patient, it is important that care plans are up to date. Accurate patient information should therefore be updated from time to time as they progress towards the desired goals.

 

Make Sharing Easy

To enable easy access and sharing of the same information, it is important that the NCP is available in formats that enable sharing, easy. For instance, it should be stored electronically.

 

How to Write a Nursing Care Plan

 

This section offers a step-by-step guide for nursing students, those looking to join nursing schools, and other healthcare providers on how to come up with a comprehensive nursing care plan to be used to provide holistic patient care.

Step 1. Collection of Data

Creating a client database is the first step towards writing a nursing care plan.

Data collection techniques such as examining the patient’s medical history, review of the patient record as well as assessing the physical health of the client are important in building the database of the patient for individual-focused care.

At this stage, the nurse identifies risk factors and characteristics that are used in the formulation of a nursing diagnosis

Step 2. Analyzing and Organizing the Data

After the information is gathered, it is sorted and analyzed in order to come up with a diagnosis and the desired outcomes.

Step 3. Developing Your Nursing Diagnoses

A nursing diagnosis is key in forming the basis of nursing interventions that should be taken. They are developed from the data that has been collected and analyzed from the above steps.

The nursing diagnosis is important because it;

  • Identifies the priorities and directs the nursing interventions towards those priorities.
  • Acts as an evaluation basis to determine whether the nursing care was cost-effective as well as beneficial to the patient.
  • For third-party stakeholders, it provides a benchmark for quality assurance.
  • It acts as an effective teaching tool for nursing students in nursing school. This is because it enhances their critical thinking skills by putting into practice their learning.
  • Enhances communication among the healthcare team by providing a standard communication basis. This makes it a great collaboration tool among the staff.
  • Is important in identifying how an individual patient or a group respond to certain health or life process, by directing resources towards solving or eliminating problems that might be a hindrance to the nursing process.

Step 4. Listing priorities

In this step, the needs are prioritized starting from the ones that are considered to be the most important (physiological needs). To determine the ranking of these needs, Maslow’s hierarchy of needs, developed by Abraham Maslow is used.

Maslow’s hierarchy lists down human needs as follows

  • Basic physiological needs. This means the NCP developed by nurses should first address needs like nutritional intake, cardiovascular health, proper oxygen circulation for breathing, and adequate sleep.
  • Safety and security. The nurses together with other care providers perform measures to avoid injuries or prevent illnesses, through nursing actions such as handwashing. To enhance a feeling of security, nurses also cultivate a relationship based on trust with the patient.For physical security, the installation of safety guards like handrails is put in place.
  • Love, and belonging. To avoid feelings of loneliness or neglect, it is essential for the patient to feel supported through adequate healthy and supportive relationships. At the same time, toxic interactions such as bullying should be prevented. physical therapists can contribute to feelings of love and belonging by offering listening sessions for the patient as part of the patient care plan.
  • Self-esteem. The patient should be motivated to keep a positive outlook for their life through interaction with members of the community, creating empowering environments, and enhancing a sense of control for the patients to enable a level of independence. The nurse can also encourage the patient to accept their conditions as part of helping them live a full life.
  • Self-actualization. To enable the patient to live a full life and reach their maximum possible potential, a nurturing home health environment should be present as well as encouraging spirituality and motivation through hope. 

Step 5 . Patient Goals and Desired Outcomes

Depending on the patient’s diagnosis, the nurse writes down a list of goals to be achieved. These goals can either be long-term goals or short-term goals.

Whether the goals are long-term or short-term, they should all be SMART in nature. That is

  • Specific. The goal should be particular in nature so the objective is clear from the start. It should offer clarity and a clear sense of direction. Assessment cues will offer guidance as to the nursing interventions toward the achievement of the goal. An example of a short-term specific goal is ensuring the patient is getting nutritious meals. An example of a long-term specific goal is enhancing the patient’s mobility through continuous physical therapy. 
  • Measurable. This means that it can be tracked over a duration of time that has been arrived at through scientific explanation. For instance, the patient should get nutritious meals three times a day after every three hours or monitor the vital signs of a patient after a session of physical therapy.
  • Achievable. The goal should be flexible and attainable. It should be something that can be reachable and still flexible.
  • Realistic. The goals should be set based on the available resources and patients’ ability.
  • Timely. The goals should specify the timeline set for achieving the outcomes.

Step 6. Nursing interventions Selection

Nursing interventions can be described as the treatment guide and the nursing process that the nurses will follow towards the achievement of the listed goals and outcomes.

There are three types of nursing interventions

  1. Independent intervention. Here, the nurse has enough knowledge- based on her critical thinking skills, years of practice in patient care, and thorough learning in clinical nursing-, to administer care without the help or supervision of a physician. For example, a nurse can encourage a patient the importance of completing their dosage by explaining some of the benefits of ta and the risk factors associated with lack of completion.
  2. Dependent intervention. This is where the nurse with the guidance of another authority for instance a physician is directed to give certain interventions as per the physician’s orders. For example, the administration of a particular kind of medication or checking the patients vitals are examples of dependent nursing interventions
  3. Interdependent/ collaborative intervention. The nurse and the other members of the care team, come up through a joint effort to provide the nursing care. Some of these team members are physicians, physical therapists, social workers in nursing homes for the greater wellbeing of the patient.Nursing interventions are usually grouped into seven categories
    • Family nursing interventions
    • Behavioral nursing interventions
    • Basic psychological interventions
    • Complex psychological intervention
    • Community interventions
    • Safety nursing interventions
    • Health system interventions

 

Step 7. Rationale provision

Here, the nurse offers an explanation based on a scientific explanation for why the nursing intervention was used in patient care. This step is usually used by nursing students to show the connection or proof for why a nursing invention was selected over others.

Evaluation

The NCP is examined from the first step to the last step to determine whether the interventions that were used achieved the desired outcomes.

This is a continuous process of the NCP because through the conclusions drawn, the team determines whether some changes should be made and whether some interventions should be terminated if they have outlived their usefulness.

 

Recording on paper

Finally, the NCP is complete, and to sum up this nursing procedure, the process is documented and stored in what will be part of the patient’s permanent medical record at the institution in accordance with the hospital’s policy.

 

As detailed above, a nursing care plan is an essential part of delivering holistic patient-centered care. In order to deliver that care, it should essentially answer three most important questions; what is ailing the patient or what are the risk factors exposed to the patient, why does the patient suffer from this or why can this risk expose the patient to danger or an illness, and lastly, how can the situation be made better for the patient and through what measures.

Integrating evidence, better communication channels, and collaboration between working nurses and other members of the staff, all while ensuring the best care is given to a patient, are some of the fundamental guidelines and planning interventions that are used to measure nursing care.

 

April 18, 2022

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