How to Write a Nursing Care Plan
What Is a Nursing Care Plan?
A nursing care plan is a document that contains information about the patient’s diagnosis, possible risks, special care to provide, and desired outcomes. This plan aims to provide effective communication among healthcare providers that are involved in the treatment process.
Undoubtedly, a nursing care plan writing process is an essential part of patients’ care. The overall result of the treatment will greatly depend on this document. The lack of a nursing care plan can cause irreparable harm to the patient’s health. So it is crucial to write a nursing care plan according to all the standards. In this article, you will find out about the components of every nursing care plan and the steps on how to write it perfectly.
Nursing Care Plan Main Components
There are five important components that should be included in a nursing care plan. Here they are:
- Client assessment that contains all the information about the patient’s medical history
- Desired outcomes that can be planned for a long a short time period
- Interventions that stand for plan nurses should follow to achieve the outcomes
- The rationale that explains the reasons why these interventions were chosen
- Evaluation that describes how well the interventions helped to achieve the outcomes
The combination of these components in a nursing care plan will create a full picture of how the care should be provided for the patient to reach the goals of the treatment.
Steps on How to Write a Nursing Care Plan
When writing a nursing plan multiple times, it comes in handy on what the procedure is. However, if you wish to learn about and practice it, just follow the steps below.
- Gather data and find all the information about the client in the client database
- Analyze the information and think of the diagnosis and the outcomes
- Set a nursing diagnosis
- Plan the needs according to the highest priority level
- Create the goals of nursing care
- Choose the proper nursing interventions
- Explain the use of interventions with a rationale
- Evaluate the client’s case and how it will improve using the selected interventions
- Write a holistic nursing care plan as a part of the medical record
What Are the Nursing Care Plan Fundamentals?
The fundamental things that the nursing care plan should cover answer the what, why, and how questions.
Under the what question, you should answer what your patient is suffering from, what is the further plan of treatment and what possible risks to avoid.
Concerning what you have to put in the nursing plan, it’s why this is happening to your patients and why the risk occurs.
And the last question will help you to plan a nursing care answer with the steps on how to make the patient’s state better and in what ways.
With all this information shared, you will be ready to create your nursing care plan easily!