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How to Write A Nursing Care Plan
Writing the best nursing care plan requires a step-by-step approach to correctly complete the parts needed for a care plan. In this tutorial, we have the ultimate database and list of nursing care plans (NCP) and NANDA nursing diagnosis samples for our student nurses and professional nurses to use — all for free! Components, examples, objectives, and purposes of a care plan are included together with an elaborate guide on how to write an awesome nursing care plan or a template for your unit.
A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, quality and consistency in inpatient care would be lost.
Care plans include the interventions of the nurse to address the client’s nursing diagnoses and produce the desired outcomes.
Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice. How to Write A Nursing Care Plan
Care plans can be informal or formal: An informal nursing care plan is a strategy of action that exists in the nurse‘s mind. A formal nursing care plan is a written or computerized guide that organizes information about the client’s care. Formal care plans are further subdivided into standardized care plans, and individualized care plans: Standardized care plans specify the nursing care for groups of clients with everyday needs. Individualized care plans are tailored to meet the unique needs of a specific client or needs that are not addressed by the standardized care plan.
Objectives
The Following Are the Goals And Objectives Of Writing A Nursing Care Plan:
The following are the purposes and importance of writing a nursing care plan:
Components
A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales. These components are elaborated below:
Nursing care plan formats are usually categorized or organized into four columns:
(1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. Some agencies use a three-column plan wherein goals and evaluation are in the same column. Other agencies have a five-column plan that includes a column for assessment cues.
A 4-column care plan format
Below is a document containing sample templates for the different nursing care plan formats. Please feel free to edit, modify, and share the template.
Student care plans are lengthier and more detailed than care plans used by working nurses because they are a learning activity for the students.
Student nursing care plans are more detailed
Care plans by student nurses are usually required to be handwritten and have an additional column for “Rationale” or “Scientific Explanation” after the nursing interventions column. Rationales are scientific principles that explain the reasons for selecting a particular nursing intervention.
How do you write a nursing care plan (NCP)? Just follow the steps below to develop a care plan for your client.
Example of goals and desired outcomes. Notice how they’re formatted/written.
One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are oftentimes used interchangeably.
Short Term and Long-Term Goals on How to Write A Nursing Care Plan
Goals and expected outcomes must be measurable and client-centered. Goals are constructed by focusing on problem prevention, resolution, and/or rehabilitation. Goals can be short term or long term. In an acute care setting, most goals are short-term since much of the nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended-care facilities. How to Write A Nursing Care Plan
Components of Goals and Desired Outcomes of How to Write A Nursing Care Plan
Goals or desired outcome statements usually have four components: a subject, a verb, conditions or modifiers, and criterion of desired performance.
Components of goals and desired outcomes in a nursing care plan.
When writing goals and desired outcomes, the nurse should follow these tips:
Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. As for risk nursing diagnoses, interventions should focus on reducing the client’s risk factors. How to Write A Nursing Care Plan. In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step.
Types of Nursing Interventions
Nursing interventions can be independent, dependent, or collaborative:
Types of nursing interventions in a care plan.
Nursing interventions should be:
When writing nursing interventions, follow these tips:
Rationales, also known as a scientific explanation, are the underlying reasons for which the nursing intervention was chosen for the NCP.
Sample nursing interventions and rationale for a care plan (NCP)
Rationales do not appear in regular care plans, they are included to assist nursing students in associating the pathophysiological and psychological principles with the selected nursing intervention.
Evaluating is a planned, ongoing, purposeful activity in which the client’s progress towards the achievement of goals or desired outcomes, and the effectiveness of the nursing care plan (NCP). Evaluation is an important aspect of the nursing process because conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed.
The client’s NCP is documented according to hospital policy and becomes part of the client’s permanent medical record which may be reviewed by the oncoming nurse. Different nursing programs have different care plan formats, most are designed so that the student systematically proceeds through the interrelated steps of the nursing process, and many use a five-column format. How to Write A Nursing Care Plan
Nursing Care Plan List
In this section, we list down the sample nursing care plans (NCP) and NANDA nursing diagnoses for various disease and health conditions. They are segmented in categories:
Basic Nursing and General Care Plans
Miscellaneous nursing care plans examples that don’t fit other categories:
Surgery and Perioperative Care Plans
Care plans that involve surgical intervention.
Maternal and Newborn Care Plans
Nursing care plans (NCP) related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
Pediatric Nursing Care Plans
Nursing care plans (NCP) for pediatric conditions and diseases:
Cardiac Care Plans
Nursing care plans about the different diseases of the cardiovascular system:
Endocrine and Metabolic Care Plans
Nursing care plans (NCP) related to the endocrine system and metabolism:
Gastrointestinal
Care plans (NCP) covering the disorders of the gastrointestinal and digestive system:
Genitourinary
Care plans related to the reproductive and urinary system disorders:
Hematologic and Lymphatic
Care plans related to the hematologic and lymphatic system:
Infectious Diseases
NCPs for communicable and infectious diseases:
Integumentary
All about disorders and conditions affecting the integumentary system:
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Mental Health and Psychiatric
Care plans for mental health and psychiatric nursing:
Neurological
Nursing care plans (NCP) for related to nervous system disorders:
Musculoskeletal
Care plans related to the musculoskeletal system:
Ophthalmic
Care plans relating to eye disorders:
Respiratory
Care plans for respiratory system disorders:
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