Nursing care plan writing

In this, we’re going to look at how to write a nursing care plan. If you’re in school right now, you’re probably super frustrated, annoyed, and confused by the whole nursing care plan process. What goes in which box, how do you write an appropriate nursing diagnosis? It can be really overwhelming. What we want to do is really simplify it for you so that you don’t try to make it this big formal rigid thing.

How to Write Nursing Care Plan Papers

The best part about thinking through nursing care plans is that it’s really just the nursing process in action. First, we assess – we gather our information. Then, we diagnose – we figure out what the problem is. I’ve recently started including prioritize in here, because we need to then look at those problems and decide which ones are the most important. Then, we make a plan – what are we going to do. Then, we implement that plan, and evaluate whether or not it worked. The only real difference in the nursing care plan process is that we put this all on paper by just anticipating what we should see in the evaluation step – or by setting goals. But either way, it always goes in this order.

Steps of Writing a Nursing Care Plan

So what we’ve done is broken down the nursing care plan writing process for you into 5 easy steps. They are: collect information, analyze the information, ask how, translate, and transcribe. So let’s look at each of these steps in detail!

Step 1- collecting information:

The first step is to gather all the information about the patient. This is your assessment step – gather all data. That includes all subjective and objective data. In this step, you need to explain what is going on with your patient and include their history. Describe your assessment findings and current vitals. What is the patient reporting? Are they in pain? This really just data mining, we’re getting as much information as we can. This is going to be done with your chart review and your first head to toe assessment.

Step2- Data analysis

Once you have all the data you need, you’re going to analyze it. This is when we get to diagnose and prioritize steps. Of all the information I gathered, what information actually points to there being a problem? What is something going on with my patient that actually needs to be improved? Maybe their skin is red or their blood pressure is too high? The big thing you want you to look at here is what an actual problem versus a potential problem is. Just because they have a history of hypertension doesn’t mean that coronary perfusion is an issue, right? But is it a potential problem? And then, of course, start to prioritize these problems. Actual problems will ALWAYS take priority over potential problems. And most of the time, if you’re in school you’ll be asked to choose 2 or 3. So pick your top 2 or 3 priority problems.

Step 3- Treatment plans

Then the next step is to ask your how questions. These questions are going to help you with your plan, implement, and evaluate phases. You can ask how did I know this was a problem – this is where you start really linking the pieces of data together. Which assessment findings were significant enough to tell you there’s a problem – how did you know? Then you can ask how would you address it? What needs to be done about it? This is where you start building your interventions. Then, ask yourself – how would I know if this got better? How will I know if my interventions worked? This is how you think through the evaluate stage and you can even start to set your expected outcomes or your patient goals at this point.

Step 4- Translating Data

So your next step here is Translate. What this really means is that you put the information you just gathered into the terms you need. Some programs will use Nursing Concepts, which are just high level categories like perfusion, oxygenation, infection control, etc. Other programs are using NANDA nursing diagnoses and the NIC and NOC terminology. Here, you want to write the nursing diagnosis you chose, related to whatever is causing it, as evidenced by the data that tells you it’s a problem. So, you just need to know which terminology you’re using. At this point, do not force words, just state what the problem is for your patient. So – if you do have to pick certain terminology, this is the point at which you would do that. Bu the most important thing is to just articulate the major issues.

Step 5- Writing your nursing plan paper

That just means get it on paper – make it official. The big thing to know when you start putting your plan onto paper is don’t include any information that’s unrelated or unnecessary. Just include the things that are applicable to the problem you’re talking about. The other thing you’ll want to do is make connections between all the associated information. So you’ll write the problem you identified – or the nursing diagnosis, or concept, whatever it is – then you’ll want to include the data that told you that was an issue, the interventions you chose and the rationale, and then what your expected outcome is. But again, let’s simplify this – you want to write down what’s wrong, how you know it’s wrong, what you’re going to do about it and why, and what you’re expecting to see! That’s it! That’s all a nursing care plan really is.

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