Writing a Nursing Care Plan

How to Write a Nursing Care Plan?

Medicine has changed greatly over the last few generations. The days when patients repeatedly visited the same family physician are gone. Today, patients commonly consult teams of specialists, including—but not limited to—doctors and nurses.

These care teams are greatly assisted by records that document a patient’s history and medical treatment and chart a health care plan, often referred to as a nursing care plan. Though this medical “road map” has long been associated with nursing, it actually involves an interdisciplinary team. A caregiver unfamiliar with a patient/resident should be able to find all the information needed to care for a patient in the care plan.

Steps of writing a nursing care plan

The first step in care planning is a quality assessment, followed by reassessments, if necessary. There are established protocols for initial assessments and ongoing reevaluations, depending on the situation.

The initial assessment is used to generate a “problem” list, which may be as simple as a list of medical diagnoses. Despite its name, this list may also include a patient/resident’s strengths, along with family or relationship problems which may affect the person’s overall well-being.

A healthcare provider can consult the list, asking whether each problem will get better (or “Can we make it better?”). If the answer is yes, then the goal becomes resolving or improving the problem.

If the answer is no, the healthcare provider asks another question: “Can we keep this from getting any worse or developing complications?” Diabetes and congestive heart failure are examples of problems which typically don’t get better but can be managed. The health care provider should set down specific and measurable goals, such as maintain blood sugar within an acceptable range.

Alzheimer’s disease and nutritional problems associated with a terminal condition are examples of problems that call for the final question: “How can we make this person’s remaining days as comfortable and dignified as possible?” The goal then becomes providing optimal quality of life. Ironically, this may be the most complex scenario, as the health care team, the patient and the patient’s relatives may not always agree on what quality of life entails.

Obviously, a nursing care plan must be flexible, adapting to changes in the patient’s condition and circumstances. The care planning process ends when the patient or resident is discharged or dies.

Summary of what a nursing care plan is

A nursing care plan consists of

  • An accurate & comprehensive assessment of the patient and their conditions
  • A list of the patient’s problems
  • A set of reasonable, specific, and measurable goals. (The goals can be to resolve problems or limit additional problems.)

Functions: A nursing care plan

  • Provides a continuous, flexible plan of care, from the time a patient’s care begins until they are discharged or expire
  • Gives information to caregivers who are unfamiliar with the patient
  • Guides all patient care providers
  • Ensures optimal patient outcome

How a good nursing care plan should look like

By now, you should understand the importance of a nursing care plan. But does a nursing care plan guarantee success?

Not at all. After all, injuries and disease are unpredictable, as are patients’ bodies and environments. But there’s one element you have a great deal of control over — the nursing care plan; make sure it’s a good one.

So what is a good nursing care plan?

  1. Good nursing care plans exhaust all options pertaining to a patient’s diagnoses and care.
  2. Good nursing care plans have good rationale for the expected patient outcomes.
  3. Good nursing care plans have realistic goals.
  4. Good nursing care plans use jargon that is easy for the appropriate personnel to understand.
  5. Good nursing care plans use correct spelling.
  6. Good nursing care plans feature accurate diagnoses.
  7. Good nursing care plans require short, frequent contact with patients.

To further put things in perspective, imagine if you asked a patient to write their nursing care plan. Most patients would want to be properly diagnosed and would want to know about all their options, including the risks each one offers. They would want lots of attention, and they would certainly want to be able to read and understand their care plan. To put it another way, a nursing care plan should be as good as your patient deserves.

Nursing care plan template

Our team at NursingPaper has compiled a collection of nursing care plan samples. Hopefully, they will help you to understand what makes a good care plan.

  • Generic Nursing Care Plan – It shows the sections of a nursing care plan and describes what information should be listed.

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  • Diabetes Nursing Care Plan – This is an actual nursing care plan for a diabetic patient. It demonstrates the proper placement of essential information.

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  • Patho Nursing Care Plan – This is the pathophysiology section of a nursing care plan. It demonstrates the types of information that are needed in this part of a nursing care plan.

Three parts to a patho

1. Normal A&P of disease
2. Disease process – define cause, signs and symptoms, lab values, treatment
3. List what the patient was admitted with.

Nursing care plan example

Pancreatitis

The pancreas, located in the upper left quadrant of the abdomen, is an organ that has both exocrine and endocrine functions. The exocrine function involves the secretion of pancreatic enzymes through the pancreatic duct to the small intestines. Amylase breaks down carbohydrates, lipase brakes down fat. Protien is broken down by trypsin, chymotrypsin, and carboxypeptidase. The endocrine portion of the pancreas consists of the islets of Langerhans which secrete the homones glucagon and insulin.

Pancreatitis, inflammation of the pancreas, is the result of autodigestion in which the normally excreted pancreatic enzymes digest the pancreatic tissue. It can be either acute or chronic. The most common cause of acute pancreatitis is heavy alcohol consumption and biliary tract disease. Alcoholism is the most common cause of chronic pancreatitis. Signs and symptoms include severe abdominal pain radiating to the back, fever, rapid pulse, shallow respirations and hypotension