How to write the best nursing care plan

How to write the best nursing care plan

To write the best nursing care plan, it is essential to follow the steps needed to complete the process. Some students find it challenging to follow all the steps, which may lead to scoring low grades on the assignment. This article contains a complete guide on how to write the best nursing care plan.

When assigned nursing care plan assignments, some students write independently while others look for a nursing care plan website to help them. This depends on if you understand how to do a nursing care plan. Whichever path you might decide to take, it is your choice.

What is a nursing care plan?

A nursing care plan is a process of identifying possible needs and risks of a client and deciding the actions to take to improve the situation. A care plan provides communication between a nurse, a patient, and other healthcare provider to achieve all healthcare outcomes. When there is no healthcare plan in the hospital, it is easy to lose the consistency and quality of a patient.

A nursing care plan starts immediately after a patient is admitted to the hospital. It is usually updated as the condition of a patient changes and as the achievement of the goals is assessed. Success in the nursing action is based on the provision and planning of individualized nursing care centers.

Step-by-step guide on how to write a nursing care plan

  1. Data assessment and collection

The first step of the nursing care plan involves creating a database of the client using assessment techniques and data collection methods. These methods include a patient’s health history, physical assessment, diagnostic studies, and medical records review. A patient database has all the health information collected.

During this stage, a nurse can quickly identify the risk factors and define the characteristics that can be applied to develop a nursing diagnosis. Different nursing schools have other formats that can be used for the nursing diagnosis process. Though this stage is very crucial, if you understand what is a care plan in nursing, it is easy to go through this stage.

  1. Data organization and analysis

This involves organizing all the data and information collected. After a nurse obtains all the patient information, they start clustering, analyzing, and managing it. This helps in formulating priorities, desired outcomes, and a nursing diagnosis.

  1. Formulating a nursing diagnosis

Formulating a nursing diagnosis depends on the information collected. Be very careful in this process as it is easy to misinterpret data. You can consider looking at nursing care plan examples online.

North America nursing diagnosis association (NANDA) provides a way of identifying, focusing, and dealing with patients’ individual needs and how to respond to high-risk and actual problems. Possible health problems that can be resolved or prevented by the autonomous intervention of a nurse are referred to as nursing diagnoses.

  1. Set the priorities

Choosing a preferred order for addressing nursing diagnoses and therapies is known as setting priorities. In this step, the nurse and the patient start deciding which nursing diagnostic has to be addressed first. Diagnoses can be categorized and classified according to their low, medium, or high priority. Issues that tend to be Life-threatening ought to be treated with extreme priority.

Maslow’s Hierarchy of Needs is covered by a nursing diagnosis, which aids in planning and prioritizing care based on patient-positioned outcomes. Abraham Maslow created a hierarchy based on the fundamental wants that are inborn in every person. Before achieving stronger desires and objectives, such as self-actualization and self-esteem, primary physiological goals and needs must be satisfied. The foundation for implementing nursing interventions and care is based on safety and physiological needs.

Maslow’s hierarchy of needs includes

  • Basic needs of psychology
  • Security and safety
  • Self-esteem
  • love and belonging
  • self-actualization
  1. Establishing the desired outcomes and the goals of the client

The nurse and the patient develop goals for each priority determined after allocating significance for the nursing diagnostic. Using nursing interventions based on the patients’ diagnoses, the nurse aims to attain specific goals or desired results. Plans give direction for designing interventions, act as standards for assessing client progress, allow the client and nurse to identify which issues have been resolved, and inspire both parties by giving them a sense of accomplishment.

The goal must be specific, measurable, action-oriented, realistic, or timely. Depending on the situation, the nurse and the client may develop short-term and long-term goals. Check free nursing care plan examples to understand how goals should be.

  1. Selection of nursing interventions

These include actions or activities a nurse practitioner performs to achieve the goals set by the client. The interventions selected should concentrate on reducing or eliminating the origin or cause of the diagnosis. For diagnosis involving risks, the nurse should deal with the client’s risk factors.

At this stage, identify the nursing interventions and write them down during the planning stage of the nursing process. You will perform them at the stage of implementation. Nursing interventions can be dependent, independent, or collaborative. When writing down the interventions;

  • Ensure you write the date and sign the plan
  • Ensure your plan is stated and specific
  • Use abbreviations that are only accepted in your school
  1. Provide a rationale

A rationale is also referred to as a scientific explanation. Explain why you chose the nursing intervention. While writing regular nursing plans, do not include a rationale. Include them when you need help associating psychological and pathophysiological principles with the selected nursing intervention. Check impaired skin integrity nursing care plan to understand this stage well.

  1. Evaluation stage

In this stage, assess the success of your nursing care plan and progress towards achieving the goals. Evaluation is a crucial stage of this process, but you do not have to worry if you understand what nursing care plan is. At this stage, you should determine if to continue or stop depending on the conclusions made in the nursing process.

  1. The writing processes

Document your nursing care plan according to the policy of the hospital. This becomes a patient’s medical record that nursing practitioners can use in the future. Different programs have different nursing care formats. Most of them are designed for students to proceed through the nursing process’s interrelated steps systematically. Ensure you use the correct nursing care plan template as your instructor requires.

To sum up

To write a successful nursing care plan, you must plan, practice effective communication, evidence-based practice, and goal-oriented tasks. This guide has made it easy by outlining the step-by-step guide on how to write a nursing care plan.

If you still need help writing your nursing care plan, reach out to the best website for writing a nursing care plan. We provide nursing care plan help to students all over the world.

 

 

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