How to write Nursing Care Plan

The nursing care plan is a document that nurses record during patient evaluation. The nursing care plan must include the specifics of the patient’s diagnosis, treatment procedure, and intended outcome, as well as medication and appointment dates, and a plan for a final evaluation after the specified number of days.

Table of Contents

The primary objective of nurses is to save lives and assist patients in managing incurable conditions. They prescribe a treatment plan for the circumstance. A nursing care plan also specifies the optimal treatment procedure, its implementation, and any potential hazards. This plan differs depending on the diagnosis and cannot be considered universal.

In instances where the patient is to be treated at home, nurses are expected to instruct caregivers on how to implement the plan. With occasional oversight, family members can provide care for their patients. A number of care plans are available for nurses to subscribe to. The nursing staff can prescribe the following care plans and diagnoses or procedures. Let us now discuss a variety of prescribable nursing care plans.

Wondering where to begin with care plan writing? The essential components of a nursing care plan include assessment, diagnosis, planning, implementation, and evaluation.

Assessment

This is the initial phase of data collection from either the patient or the caregiver. The nurse is expected to think critically about the provided queries and answers.

Diagnosis

The nurse’s diagnosis will recommend prescribing such care.

Planning

At this juncture, the objective and outcomes are formulated. Appropriate plan of care for the patient. During this phase, nurses set objectives that are specific, measurable, achievable, realistic, and time-bound.

Implementation

This is where the developed care plan is implemented. These could range from injections to the administration of oxygen or ventilation to the patient. This is the phase of action.

Evaluation

Here, nurses determine whether the action plan was successful or not. They become aware of the plan’s limitations and, if necessary, regroup to develop a new plan that is impregnable. In order to make an accurate assessment, nurses may consult medical records.

Components of a nursing care plan

Writing care plans is part of a nurse’s responsibility to their patients and the nursing facility. This plan is a component of patient recordkeeping, and it promotes continuity even when the administering nurse is absent. When creating a care plan, nurses must adhere to specific formats and record specific information. Errors in the writing of the care plan can lead to the incorrect diagnosis and prescription, which could result in the patient’s mortality.

When composing nursing care plans, nurses should consider the steps below.

The nurse must evaluate the patient and be able to analyze the exhibited symptoms.
The nurse must formulate a potential diagnosis in order to investigate alternative treatment options. This could depend on the gravity of the situation.
The nurse must establish rapport with the patient and establish objectives. This will inform the nurse of what to anticipate from the prescribed care plan.
The nurse must monitor the patient’s progress and be willing to modify the care plan as necessary. Nurses must be adaptable in order to modify the care plan if the initial objective is not met.

Analysis of the proposal

Depending on the type of diagnosis, the writing of a care plan for a given patient could vary. Nurses must also instruct caregivers on how to handle patients with urinary retention and catheters, among others.

The planning of nursing diagnoses, interventions, and outcomes

The purpose of the assessment, diagnosis, and evaluation phases is to formulate an optimal care plan. The nurses must evaluate and assess the accomplishment of their plan. This enables them to use it as a basis for other decisions when developing a care plan.

The diagnosis must be communicated by nurses to patients and caregivers. These care plans are prescribed by nurses at the time of discharge for conditions that can be managed at home.

Let’s now discuss some examples of nursing care plans and the factors that nurses must keep in mind when writing care plans.

Postpartum nursing care plan

Postpartum nursing care is the plan of care prescribed by nurses to the new mother, depending on the form of delivery, which may be a natural birth or a C-section birth. It is always a delight for every mother to emerge from postpartum in good health.

Postpartum care is provided to both the mother and neonate. The breastfeeding pattern of the infant, bilirubin screening, mother and child attachment care, infection on the c-section or episiotomy site, and childbirth-related trauma to the mother are under observation.

Normal maternity care plan

Due to the restriction on C-section childbirth, every woman desires a normal delivery.Normal birch also has a care plan that the nurses prescribed for the episiotomy, which includes the following:

Warm bath chair

After evaluating the quantity of bleeding, a prescription was issued.
Utilization of postnatal pads
Cleaning oneself from front to back following a C-section delivery.

This is a crucial operation to save the mother and child. Some women choose it voluntarily, while others are compelled by a birth canal that is insufficiently dilated.

Wound treatment

Infection of the surgical site
Anxiety
A headache caused by the anesthetics.

Plans for diabetic nursing care

Diabetes is a condition in which the body is unable to produce or utilize sufficient amounts of insulin. As a consequence, the body stores a great deal of sugar, which eventually leads to diabetes.

After receiving a diagnosis and treatment for diabetes at the facility, the patient is discharged under the supervision of family members in accordance with a nurse care plan.

The prescribed treatment plan include:

Dosage administration.
Diet supervision
Management of stress among others

Plans for psychosocial nursing care

Psychosocial patients are a group of patients suffering from mental disorders, poor emotional and social health, and chronic diseases such as cancer and HIV/AIDS, among others.

The nurses caring for such patients are given encouragement and a positive outlook on life. The plan calls for the nurses to evaluate the patients’ self-esteem and provide training to the caregiver, who will be expected to provide the patient with emotional, psychological, and financial support.

Plans for nursing care for pneumonia

Pneumonia is a disease that affects the air sacs. This makes it difficult for affected patients to breathe. Before developing a care plan, nurses must diagnose and treat the infection and comprehend the patient’s history.

In the majority of cases, nurses must admit patients to the ventilator. In their care plans, nurses must include instruction on how to care for the patient at home and how to maintain the environment. Most patients are treated with medication or ventilation.

Plans for hospice nursing care

Hospice care programs are for chronically ill patients. Cancer and tumors are among the illnesses for which hospice care arrangements are required. After diagnosing a patient, nurses administer medication.

Planned hospice care would include nursing care for depression because patients receiving such care are susceptible to depression and other mental disorders. The residential treatment plan must also be provided alongside the scheduled appointment. End-of-life nursing care programs would double the number of hospice patients. This is for pain management, as the patient experienced excruciating agony at times. The phrase end-of-life because the suffering and illness would ultimately last a lifetime.

Plans for nursing care for atrial fibrillation

Atrial fibrillation is an irregular yet extremely rapid heart rhythm induced by the heart’s structure. When composing a nursing plan, nurses must consider the patient’s family history as part of the diagnosis and nursing care plans for hypertension. A provisional caregiver plan and education must be provided for drug-based home management, and appointments must be scheduled. Additionally, caregivers must be educated on the danger signs and when to contact for help. These patients may also be covered by tia nursing care plans.

COPD nursing care programs

This is due to respiratory difficulties. The nurses are to collect data and assist the patient in reducing anxiety in order to regulate the pulse, after which the patient can be administered oxygen. The patient can then be evaluated after the care plan has been implemented. In the event that a patient is discharged, the attendants must be trained on when to contact the hospital and how to care for the patient.

The nursing care plan includes diagnoses

At the diagnosis stage, nurses use clinical judgment to determine the care to be administered. The clinical judgment could be derived from the North American Nursing Diagnosis Association (NANDA), which provides nurses with an up-to-date list of possible diagnoses, such as severe headaches in the lumbar region, urinary retention, edema, liver infection, etc.

During the diagnostic process, nurses may utilize literature references. Nurses use a three-phase diagnosis procedure, which consists of the problem-focused nursing diagnosis, which includes the patient’s responses, all contributing factors to the diagnosis, and the patient’s observable signs and symptoms.

aims of nursing care programs

A nursing care plan is intended to aid in the documentation of the patient’s requirements and potential outcomes, as well as nursing interventions and implementations. The care plan is also included in the hospital’s health record because it ensures the continuity of treatment for the patient.

While producing the care plan, nurses are expected to establish the plan’s bare minimum requirements. The plan must adhere to the SMART criteria. S stands for Specific, M for Measurable, A for Attainable, R for Realistic, and T for Time-bound.

short- term and long-term objectives of a nursing care plan

Short-term purpose.

A short-term objective in the nursing care plan would be to temporarily resolve the situation. These remedies may not last the patient for very long. Depending on the circumstances, it could only be maintained for a few days or hours. Such objectives could be used with palliative patients.

Long-term target.

In nursing care plans, these long-term objectives may last for weeks or months. These could occur in diabetic patients who are monitored at home by caregivers. Would you like to compose your nursing care plan? Get a custom one completed from scratch here

Summary

The five main components of a nursing care plan are assessment, diagnosis, planning, implementation, and evaluation. Before writing a care plan, nurses must consider and compose one based on the type of diagnosis.

The care plan for a patient must include specific, measurable, attainable, realistic, and time-bound objectives. These will be evaluated after the plan has been implemented. During the care plan formulation process, nurses may acquire data from family members or friends.