As a nurse student or professional, care plans are unavoidable in nursing school or nursing workplaces. In nursing school, student nurses are required to learn the process of writing nursing care plans in detail. That is why your instructor wants you to write care plans often. Whether you are in mental health or community care, you will write nursing care plans. Therefore, learning how to write nursing care plans is critical for any student who aspires to become a professional career nurse.
What are Nursing Care Plans and Why are they Important?
Nursing care plans are written documents or medical records that are integral to the nursing process. Even though different places may use different formats, the final documents achieve the same aim regardless of the place of application.
Essentially, nursing care plans aim at guiding nurses on how they provide nursing care to patients. They help nurses working in shifts to know the exact actions other nurses have taken for each patient. Therefore, these records are a reliable way of organizing and communicating the various actions of every health care practitioner involved in providing patient care.
More specifically, nursing care plans document assessment, diagnoses, planned interventions, and evaluation. Each aspect of the nursing care plan is an accurate process that nurses must handle with ease and care. So once you learn how to write nursing care plans, your confidence in nursing will increase, and attain better grades.
Steps to Writing Exceptional Nursing Care Plans
Nursing care plans come in different formats and thus don’t follow the same writing process. However, the following five steps can offer you guidance to writing the best nursing care plan that will satisfy your professor.
Step 1: Assessment
Assessment is the first step of the process of writing a nursing care plan. When writing this section, you need to answer a few critical questions. These questions include;
- Why is the patient here?
- Why is the patient seeking care?
- What is the patient’s general appearance?
By answering these questions, you will be able to get an accurate and comprehensive assessment of the patient’s health status. The assessment aims at collecting and recording various information about the patient. The information captured should revolve around the physiological, sociocultural, economic, lifestyle, and spiritual realm of the patient. Moreover, the assessment seeks to understand the physical causes of pain, how the pain manifests, and how the patient responds.
Step 2: Diagnosis
The diagnoses section aims at unraveling the “What” of the patient’s condition. Therefore, you will be trying to answer the question; what is the patient’s problem? The information you record as a diagnosis will help the nurses determine the kind of care the patient will receive. This section of the care plan requires a listing of the conditions and health problems a patient is under.
Step 3: Planning
In this section, you need to set specific, measurable, and attainable goals to guide care for your patient. You can come up with both short-term and long-term goals that the patient will follow. For instance, if you have an immobilized patient, what goals may you set? You may set a goal like: “The patient will move from bed to chair 3 times per day”.
Step 4: Implementation/Interventions
The implementation or interventions part mainly focuses on assisting the patient and caregivers attain the expected results or outcomes. Every patient’s record will show the specific actions the nurses require to take. Therefore, write down the actual actions that need attention including; the frequency and duration each should take. For instance, the nurse should assess the patient’s nausea every 5 hours. Or a nurse will administer pain-relieving medication as ordered or needed.
Step 5: Evaluation
Evaluation of the nursing care plan and whether the plans need modification is done in this section. This can be done by evaluating the patient’s wellness or health conditions. It can also be done by continuously evaluating the effectiveness of the nursing care services offered to the patient. The evaluation should extensively consider the effectiveness of each goal set for the patient. you can mark a goal as either “Met” or “Unmet.”
So, what if a goal is unmet? In this case, you may need to go back to the diagnosis step to make an informed diagnosis. Besides, you may also consider modifying the goals or add more interventions.
Nursing rationales are not always included in nursing care plans. However, your professor may ask you to include a nursing rationale when writing your nursing care plan. Nursing rationales can be challenging for most nursing students and writing a good one can be daunting. However, you can easily understand nursing rationales better if you can see how they interact with the nursing diagnoses, goals, and interventions.
In a nutshell, a rationale explains why a nurse sets a specific goal or chosen a particular intervention. As such, every nursing intervention needs a nursing rationale. For instance, pain control will help the patient improve their way of life by enabling them to participate in physical therapy exercises.
Without a doubt, writing nursing care plans can be challenging for not only nursing students but nursing professionals as well. Nursing students may find it difficult, especially when they cannot make the difference between the different components of a care plan. For instance, they can easily confuse Panning and Interventions parts of the care plan. Others may find it challenging to differentiate between nursing diagnoses and medical diagnoses.
However, if you are a nursing student and you are stuck with your nursing care plans, you can seek nursing care plan writing services for professional help. With nursing care plan writing services, you are guaranteed a customized care plan according to your patient’s needs with a detailed plan of actions and interventions that will enable the patient to attain the projected goals.
Besides, our well-knowledgeable and equipped writers will professionally guide you on how to write nursing care plans for various diagnoses to make you attain the best grades you need to graduate. With all these, we believe you are ready to handle any nursing care plan that may come your way!