How to Write a Care Plan
Easy steps to follow when creating a nursing care plan. -Jasmine M.
A thorough assessment must be conducted of your patient to gather pertinent information regarding the patient history. This includes subjective data that includes information that is provided by the patient and objective data that is obtained by diagnostic testing, height/weight,etc.
A diagnosis is a medical term used to identify the areas of concern or the need to provide treatment for an illness and or injury. The data that was obtained in step one (subjective and objective data) will be the foundation needed in order to determine what nursing diagnosis will be given to this patient. You will need to use a nursing diagnosis handbook or the North American Nursing Diagnosis Association (NANDA) website: https://nanda.org/publications-resources/resources/glossary-of-terms/, that provides NANDA diagnosis, interventions and outcomes. This allows you to use critical thinking skills to apply the most accurate nursing diagnosis.
Outcomes and planning is the third step required to encompass the nursing care plan. This step allows you to determine the goals needed in order to reach the desired outcome for the patient. In this step, you are able to create short or long term goals. It’s imperative to incorporate smart goals in this step. This includes:
▪ Specific: Goals needs to be specific and tailored to meet the needs of the patient
▪ Measurable: Goals need to be measurable in order to know the progress
▪ Achievable: Goals need to be achievable
▪ Realistic: Goals need to be realistic
▪ Time-bound: Goals need a time frame to determine if a goal is met or need to be adjusted
Implementation is the fourth step that is required after you have gathered all pertinent information, determined a nursing diagnosis and implemented smart goals for the disease and or injury of the patient. This steps requires interventions that will help reach the smart goals that you have set. However, this steps incorporates dependent, independent, interdependent interventions.
▪ Independent Interventions: Interventions that are able to be given by the nurse, without assistance from other medical staff. Example- administering medications.
▪ Dependent Interventions: Interventions that require a doctors order. Example-Intravenous Catheter (IV), peg tube, ordering ,medications
▪ Interdependent Interventions: Interventions that requires an interdisciplinary approach. This includes a doctor prescribing medication and or treatment, a nurse administering the medication and treatment carried out by a specialty provider. Examples include, Ophthalmology, Orthopedics, Physical therapy, etc.
Evaluation is the last step in creating a nursing care plan. This step incorporates steps 1-3 and determines if the goals have been met. The evaluation step can will continue until the patient is discharged home or until the illness and or injury has been stabilized enough to be treated at home.