How to Write a Nursing Care Plan

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How to Write a Nursing Care Plan

Are you in need of advice on how to write a nursing care plan? You’ve come to the right place because we offer affordable help for nursing students. To understand what a nursing plan of care is, how to structure it, and an example, please keep reading for tips and tricks. 

What Is A 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. Simply put, it states the patients:

  1. Personal information such as name, date of birth, and contacts
  2. Health condition
  3. Medicines, dosage, as well as how and when to administer
  4. Health insurance data

For this reason, if you need information on how to write a nursing care plan, you will need this information from the patient’s file.

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Nurses and other healthcare workers write nursing care plans or seek out a nursing care plan template because they offer the following benefits:

  • Aids in ensuring accurate communication, which is essential when dealing with healthcare
  • Helps healthcare workers achieve better outcomes
  • Defines healthcare workers' roles and makes it easier for them to contribute and collaborate
  • Nursing care plans also contribute to holistic care 
  • Helps staff formulate care pathways
  • Measures the quality of nursing care thus leading to better staff assessments.
  • Acts as a guide to other staff
  • Used by insurance companies to help with reimbursement claims
  • Ensures compliance with various regulations

To write a good nursing care plan, one should ensure that the goals are SMART:

  • Specific: the goals should be well-defined and clear
  • Measurable: there are metrics that help healthcare workers to assess progress
  • Achievable: one should make goals that can be reasonably achieved
  • Realistic: the goal should be reasonable and within reach
  • Time-bound: goals should be based on a specific timeline

If you need help with how to write a nursing care plan or any other nursing coursework help, place your order today for our nursing paper writing service

The 2 Types Of Nursing Care Plans

Just like there are different kinds of assignments in other disciplines, there are separate groups of nursing plans. These are:

1. Standardized care plans

A standardized care plan is a pre-made guide for patients undergoing particular conditions. They follow certain criteria that ensure the patient receives quality care as per standards. Since it is pre-developed, a standardized nursing care plan helps save time and increases efficiency. However, not all patients have similar needs, and most nurses can acquire a nursing care plan template before wondering how to write a nursing care plan, hence the next type of nursing care plan.

2. Individualized care plans

Unlike the standardized care plan, this plan seeks to meet the needs of a specific patient. It tends to be more personalized and can help patients battling rare conditions; hence they are common in long-term care facilities such as hospices. Patients also prefer the individualized care method since it seeks to fulfill all their needs; hence they feel heard and are more satisfied

In order to personalize a nursing care plan, one can perform a comprehensive assessment, inquire from the patient about their goals and needs, as well as performing continuous evaluation and modification as treatment proceeds. For beginners, getting correct details is a vital part of how to write a nursing care plan and should be among the first things to do when handling a patient. 

We covered these different plans in our other articles, such as the types of chemical reactions worksheet

What Are The Steps To Write A Nursing Care Plan?

In order to write a good nursing care plan, one needs to go through the necessary steps. These are:

1. Assessment

This is the first stage, and it requires data collection. In some cases, the nurse can access digital records, which they can add to the information collected. Data collected includes height, weight, past conditions, and vital signs. 

2. Diagnosis

At this stage, the nurse will develop a nursing diagnosis which involves making judgments about the patient’s health based on the data collected in the first stage. It will set the basis for the nurse’s actions, so it is important to get a correct diagnosis. 

3. Outcomes and planning

This stage involves mapping out the desired outcomes and aiming to achieve them using SMART goals that align with evidence-based practices. The goals could either be long-term or short-term, depending on the extent of care required. The planned outcome should align with the diagnosis, and results should last a long time. 

4. Implementation

Once goals have been set, the nurse may proceed with implementing measures to ensure these goals are achieved. It may use a doctor’s instructions, or a nurse may develop measures under the guidance of evidence-based practices. The interventions may fall into several categories, such as physiological, complex-physiological, family, behavioral, safety, health system, and community. You may also include the rationale behind the interventions settled upon. 

5. Evaluation

This is the final step of the nursing care plan and requires the nurse to evaluate the results and see if the expected results have been achieved. There are three possible outcomes of an evaluation if the goals were met if they are still in progress, and if they have not been met. The nurse is then able to adjust the care plan to fit the patient’s needs based on their current situation. 

Nursing Care Plan Examples

Now that you know how the different types of nursing care plans and how to outline them, you can benefit from viewing some nursing care plan examples. Researchers report that many students learn better from practical examples, so this can be used to help with learning. With regard to this, you may come across three different formats, which differ based on the number of columns. These are the three-column format, four-column, and student care plan. As you can see, there are different formats, all of which our experts handle. No matter which level or discipline you are studying, rest assured that our experts can handle it as outlined in our article on the cheapest custom research papers.

1. Three Column Format Example

Nursing Diagnosis

Outcomes and evaluation

Interventions

Risk for infection due to the poor immune system

-All vital signs are within normal range

The patient reports having a sore throat

-Provide antibiotics

Limit contact with outsiders to prevent the spread

-Provide patients with proper food to build their immune systems back up

 

2. Four Column Format Example

Swipe the table left for more details

Nursing Diagnosis

Goals and outcomes

Intervention

Evaluation

Dysfunctional gastrointestinal motility

-Reduce gastrointestinal pain

Reduce distention

-Provide the patient with anti-diarrheal medication, antacids, and antibiotics.

-Encourage the patient to walk and be physically active

-Advise patient to reduce foods that can trigger gastrointestinal issues such as dairy and caffeine.

-If constipation persists, ask them to use fiber supplements.

-Assess the patient for signs of dehydration

-Monitor lab results to check for progress e. g electrolytes and urinalysis

-Assess the patient’s fluid intake and output

 

3. Student Care Plan Example

Swipe the table left for more details

Assessment

Nursing Diagnosis

Outcomes

Interventions

Rationales

Evaluation

-Patient reports a rapid heartbeat, fatigue, cold, hair loss, pagophagia, headaches, and brittle nails.

 

-Diagnosed with anemia likely caused by her vegetarian diet and lack of sufficient vitamin B12.

An improvement in the patient’s iron and b12 levels

-Patient will consume more foods rich in iron, B-12, and folic acid.

-Patient should remain aware of the symptoms and consult the doctor if symptoms re-emerge.

 

-Advice patient to take foods like dark green vegetables, nuts, and eggs. For folic acid, they should take citrus, leafy greens, and legumes.

-Encourage the use of supplements.

-Advise patients to eat meats since the iron is more easily absorbed.

-Ask them to avoid tea and coffee as it can reduce absorption rates.

-These measures help the patient increase iron and folic acid in the body.

-The steps will help reduce the loss of iron and reduce symptoms in the long term.

-After 2 months, perform an iron test to see if the patient is better.

 

As you can see, the student care plan is more detailed compared to the other formats. This is because it is used for student nurses. For help with writing something similar, do not hesitate to place your order with our nursing paper experts today.

Aside from help on how to write a nursing care plan, we also offer help with other nursing assignments, as outlined in our article on nursing assignment help

Tips For Nursing Care

Just like with any other career, there are some tips one can implement for better results and increased efficiency. With regard to nursing care, these are:

1. Communicate with other staff

Communicating with other healthcare workers involved directly with your patient in case there are any informational gaps will help you avoid errors and focus on integral nursing priorities. Failure to have accurate data will lead to poor care and even fatal errors that can land a nurse in jail, so if there are any doubts, consult others or ask the patient. 

2. Avoid delays

Be sure to perform a particular activity when it is scheduled unless otherwise stated. This is because a delay can cost a patient their health, and acting in a timely manner can save them time and aid in their survival. While some nurses may feel overwhelmed at work and face issues accessing resources, having a planner to prevent delays will help reduce poor health outcomes.

3. Address patient concerns

At times, the patient may feel uncomfortable with certain procedures or want clarification on certain matters. If you encounter this, be sure to explain or clarify, as this will help the patient collaborate better and get involved in their care. 

4. Ask the patient if they have allergies

People react differently to substances, and at times that can negatively impact their health. As such, you should be sure to ask the patient if they have any allergies, as well as consult their medical history for more information. This can reduce the chances of adverse reactions and hence is one of the main nursing priorities.

5. Apply ethics

Healthcare workers have a code of ethics they are expected to live up to. Nurses should advocate for their patient's best interests and deliver quality care. Ethics help healthcare workers make better judgments and allow patients to exercise their values while receiving care. 

6. For every fact given, provide an action

Nursing is an active attempt to improve the health of one’s patients. To do this, one needs to learn several technical terminologies to describe a patient’s situation. While some may get caught up with describing, action is more important in nursing. It is, therefore, important to provide actions that align with the facts provided. For example, if the patient has diarrhea (fact), the recommended action should be to take antidiarrheal medication and rehydrate.

We also offer tips for other assignments related to nursing care, such as how to write a personal statement for nursing

Frequently Asked Questions

1. Should you update a nursing care plan?

Yes, a nurse care plan should be changed at least once a year. The period may be shorter if the plan needs modification due to the patient’s health changes.

2. What are the main objectives of nursing care plans?

Nurse care plans focus on the following:

  • Understanding when a patient is dying
  • Communicating a patient’s impending death or recovery
  • Offer support for the patient and their family

3. What are the ABCs of nursing when dealing with critically injured patients?

When dealing with an ill or injured patient, one should focus on airways, breathing, and circulation. Maintaining these three helps the patient survive and paves the way for additional healthcare. As such, they are integral, and nurses should consider them when asking how to write a nursing care plan.

In A Nutshell

To sum it up, a nursing plan of care refers to a document that outlines a patient’s diagnosis and needs. It offers several benefits, such as helping with compliance with regulations, better healthcare outcomes, easier communication, offering direction to other staff, helping insurance companies with reimbursement claims, and many more. The goals set need to be specific, measurable, achievable, reasonable, and time-bound to be effective. There are two main types of nursing care plans: standardized and individualized.

The standardized plan is pre-made and targets patients with common conditions, while the individualized plan is personalized for the patient in question. Since the process is new to most students, they often seek help or tips with writing them, which we have provided. However, for students seeking a quick solution to their nursing homework needs, we offer affordable nursing assignment writing services. Not only are we available 24/7, but we also offer plagiarism-free content and free revisions to help you get that A. So if you would like to knowhow to write a nursing care plan, simply place your order today for quality services.

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