How do you write a good nursing care plan?

The process of making a good Nursing care Plan is a big challenge for nursing students in Australia and even across the globe. The students would make many attempts to make it and then realise that they haven't made a proper one. But what exactly is a nursing care plan?

Well, a Nursing Care plan is a systematic plan that the healthcare staff comes up with. This care plan as the name suggests is a formal process of identifying everything that the patient would need. It is also a way for effective communication between the various nursing staff to achieve their nursing goals with their patients. Without a good nursing care plan, the efficiency of the quality and the consistency of the nursing staff would drop.

Since it is so important for students to write a good nursing care plan, we have written the steps here to write a good nursing care plan.

Data Collection or Assessment

The first step of any nursing care plan is to collect the data from the patient or research subject of the nursing student. In general, this is the part the students have the most issues with since this step requires the most experience.

The students can use both subjective and objective methods to collect the information. The subjective is the ones where the patients would explain their symptoms like the feelings and perceptions that they have. Objective methods on the other hand are those that can be, measured like body temperature, blood pressure, heart rate and such.

Diagnosis

Now the next step in the nursing care Plan is to make a diagnosis based on the data gathered from the first step. A nursing diagnosis is based on Maslow’s hierarchy of needs. For example, humans' most basic needs are food and water so they should be the priority in the nursing care plan. There are mainly four types of nursing diagnosis.

• Problem-Focused: A Diagnosis focused on resolving the problems mentioned by the patient.
• Risk: A diagnosis focused on removing or reducing Risk factors that would require instant attention from the nursing staff before the actual problem could show up.
• Health Promotion: This is the type of diagnosis that is focused more on promoting the health of a person or family.

Outcomes and planning

After the diagnosis step comes the turn of the planning stage. Here the nursing students are to use the SMART goals which are as mentioned here

• Specific: The nursing students' goals for the patient have to be well-defined and unambiguous.
• Measurable: Whatever the goals are set for the patient they have to be measurable and able to be defined in a report.
• Achievable: The goal has to be achievable. For example, the goal of having a person stop smoking in the time he is in nursing care is not achievable
• Relevant: The goal also has to be relevant to the whole Nursing care plan and not just be based on whims.

• Time-bound: And least the goal has to be time-bound and be something that could be achieved in the duration the patient is in the care unit.

This goals are based upon the Evidence-Based Practice(EBP) guidelines. Based on the patient's health, symptoms and results from their diagnosis and other aspects the students and nurses start planning. These plans have to be based on the patient's goals which have been based on

Now the goals have to be based on the outcomes too and realistic ones at that. For example, a patient who is too heavily dependent on alcohol consumption and is in the care. The goal of the nurses would be to try and have that patient get counselling but that is a completely unrealistic goal. So the goal has to be realistic too.

Implementation

Now after the planning stage comes the implementation stage. Here the planned actions have to be carried out. Some of the implementations would have instant results like using a pain medication for a patient in pain. But some could take longer. Another part of this stage is the intervention stage. As a nursing student, you will follow the doctor's and nurses' orders for the interventions but in case it is asked for practicals, the students have to follow the EBG.

Ofcourse there are some basic interventions that the student has to perform such as pain assessment, position changing, listening to the patient, providing cluster care, confirming the fluid consumption, and fall prevention.

Evaluation

The next step of a Nursing Care plan is to evaluate the plan's implementation stage and the results from that stage. It could be that the desired results were met or not and depending on that the next steps are determined. If the desired results are met then the plan is moved forward, if not then the results are evaluated and the process is checked for mistakes.

Now there are mainly two types of patients one that is in the care center for a longer duration and the other for a shorter duration. The Nursing care plans for patients who are in nursing care for longer durations require more changes and similarly constant checking too.

Putting it on the paper

Now this is the the last step of the nursing care plan. Since these plans are documents that are recorded both by the hospitals and patients they have to be perfectly documented. These documents will also become a permanent record in the patient's medical file which the future nursing care plans could be based upon. So the students have to make sure to make a well-documented report of the whole process of the Nursing Care Plan

Conclusion

The nursing care plan is one of the most important parts of a nursing student's life and hence it has to be made perfectly. The student can read the article and use the steps to make a good nursing care plan. They can then have it checked by their peers, professors, nursing seniors and even the professional writer who provides nursing care plan writing services.

A nursing care plan isn't just a done-by-the-final-step type of assignment. The student has to keep trying to get better at their various elements such as goal selection or data analysis. But these steps mentioned here can be used as a foundation for every nursing care plan by the students.