How to Write a Nursing Care Plan?
Here is the right place to get advice regarding how to write a nursing care plan that helps students understand everything about it.
What is the nursing care plan?
A nursing care plan refers to a document that contains information on a patient’s diagnosis, their needs and wants, the interventions needed, and the evaluation plan for the future.
It includes the Patients profile such as name, age, gender, Health status of the patient, treatment course (dose, duration, and route of administration), and health insurance data.
The nursing care plan is opted for by nurses and health care workers because it has its usefulness in this field
It helps in ensuring accurate communication with patients and getting better outcomes of treatment plans. Through the nursing care plan status and quality of nursing are evaluated. It helps in getting a better guide for other staff. It aids healthcare workers and staff to cooperate and collaborate effectively. It is also used by insurance companies to help with reimbursement claims
A good nursing care plan must be Specific, Measurable, Achievable, Realistic, and Time-bound. These are the qualities of a good nursing plan.
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Types of Nursing Care Plans
Standardized care plans
It has specific criteria to be met according to the patient’s specific standards. It is a pre-developed guide for patients having specific underlying conditions. Patients receive the best quality care as per standards as it has specific criteria to be met.
Individualized care plan
It encamps the needs of a patient, unlike standardized care plans. It is individual-based and is for rare conditions. It is more personalized so helps patient satisfy their query and they feel heard.
In this personalized nursing care plan thorough assessment, inquiring patients about their goals, and needs, evaluation, and monitoring of the treatment course is done.
Steps of The Nursing Care Plan
Assessment
It is the first step and includes a collection of data that is anthropometric measurements (weight, height) past medical condition, and vitals of the patients .it contains data on the health status of the patient both subjective as well as objective.
Diagnosis
Depending upon the data collected in the first step nurse makes the diagnosis of that health condition This will decide the treatment plan in the future.
Outcomes and planning
This involves formulating the outcomes and goals that are according to diagnosis, the goals may be short-term or long-term as per evidence-based practices. We can get these goals after specific nursing interventions.
Implementation of interventions
After setting goals, nurses implement the intervention and provide measures to get the desired outcomes. These intervention plans are either according to the instruction of the doctor or evidence-based practices of the nurses
Evaluation
After interventions are being set, they must be revisited or evaluated to ensure that the desired outcomes have been achieved. Monitoring and reassessment of patients is necessary to synchronize the interventional measures to that of desired outcomes. This is the final step to see if expected results have been achieved.
Example
| Assessment | Diagnosis | Outcomes and planning | Implementation or intervention | Evaluation |
| Subjective: patient states that he feels fatigued ,dizzy and breathlessObjective: pallor,spoon shaped nails ,hair fall, tachycardiaHb :7g/dlMcv:70fgMch :20pgHematocrit:32%RBC count:2.8Ferritin:4.2 | Iron deficiency anemia | STO: after 4 hours of nursing intervention, patient will be able to breath within patient range and less complaints of dizzinessLTO: After 1week of continuous nursing intervention, patient will verbalize reduction in fatigue as evidenced by reports of increased energy | Monitor Hb ,hematocrit ,rbc count and reticulocyte count.Maintain parenteral iron Injection Bisleri(100mg) diluted in 100mgN/S OD for 3 to 5 daysAdditional therapy Educate the patient regarding diet. | STO: After 4 hours of nursing intervention, patient will be able to breath within patient range and less complaints of dizziness.LTO: After 1week of continuous nursing intervention, patient will verbalize reduction in fatigue as evidenced by reports of increased energyGOAL MET |