Nursing Students Practical Guide to Writing Care Plans
Section One: The Nursing Process
Potter & Perry (2005) describes the nursing process as “a system to organize and deliver nursing care” (p.279). As you may already know, the nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation. While you have studied each of these aspects of the nursing process in depth during your core curriculum, I thought it might be helpful to provide a brief overview of how each of these steps applies to care planning.
Assessment is the deliberate and systematic collection of data (Potter & Perry, 2005). This is the very first step in writing a care plan. Indeed, it would be almost impossible to create a map of care for a patient about whom you have no information. On the evening before clinical, you will write your care plan based entirely on information you have gathered from the patient’s written records. Although you have not yet seen, touched, smelled, or listened to your patient, this research of the patient’s chart is assessment. It allows you to understand the patient’s history, reason for admission to the hospital, current medications, laboratory values, and current health status. You cannot proceed to the next step in care planning without it. Please take my advice and conduct a thorough examination of your patient’s medical record; you do not want to be at home writing a care plan only to realize that you are missing a critical piece of information.
Nursing diagnoses are clinical judgments about actual or potential problems a patient may be facing. Based on your assessment, you will identify the nursing diagnoses most appropriate for your patient. The North American Nursing Diagnoses Association (NANDA) is the organization that defines and classifies nursing diagnoses. It is required that all diagnoses included in your care plan be NANDA approved. This is important because NANDA provides a common language that all nurses use and understand. You have purchased a required text that provides you with a comprehensive list of NANDA‐approved
diagnoses. Early on in your career as a nursing student, you are expected to use
only that text as a resource. Later, you may be allowed to use several different texts on nursing diagnoses and/or care planning, depending on your instructor’s preferences, as long as all your diagnoses remain NANDA‐approved. If your instructor does not object, you will definitely want to invest in two or three nursing diagnoses/care planning books.
In your first year you will begin by identifying one diagnosis, then progress to identifying three, and then five. In your second year you will identify fifteen. You will always begin with the nursing diagnosis with the highest priority for the patient, and proceed to list the rest in order of decreasing priority. To do this, use the Basic Human Needs list (appendix A). Generally, an actual diagnosis takes priority over a risk for diagnosis. For example, Impaired Skin Integrity (an actual problem) would be a higher priority than Risk for Infection (a potential problem). However, there can be exceptions, and most of these, thankfully, can be discerned with common sense. Risk for Injury would naturally take precedence over Activity Intolerance.
The writing process is important when it comes to diagnosis. You may find it helpful to first think about and then write down on a piece of scrap paper, without regard to what is most important, any and all problems you believe the patient may have based on your assessment. From there, you can critically think about and begin to rank your diagnoses according to priority, before committing to actually writing them in your care plan.
The planning phase of the nursing process is when you will decide which care measures are appropriate for your patient. Each nursing diagnosis listed in your text will have a corresponding list of interventions and rationales. Planning care involves carefully reading though each listed intervention and asking yourself if that intervention can or should be carried out with your patient. For example, an intervention listed under Impaired Gas Exchange reads as follows: “If the patient is obese or has ascites, consider positioning in reverse Trendelenberg’s position at 45 degrees for short periods as tolerated” (Ackley & Ladwig, 2006, p.439). Now, if your patient is not obese and does not have ascites, this intervention is not indicated and should not be included in your plan of care. To reiterate, include only those care measures which are relevant to your patient.
It is very important that you learn, early on, how to make your interventions specific to your patient. Trust me when I tell you that you will likely save
yourself a lot of time, and possibly avoid having your care plan returned to you for revisions, if you are conscientious about doing this. As an illustration, suppose you have a diagnosis of Acute Pain and one of the listed interventions is “administer analgesics, as needed.” What you will need to do is look at your patient’s available medications for pain relief and write the intervention as follows: “administer Dilaudid, 2 mg, IV q 4 hours @ 0800 and 1200.” Notice that the medication, dose, route, and schedule is listed and that the times are specific to the shift when you will be caring for the patient. Also, be cognizant of the use of pronouns in your interventions. Use he or she where appropriate. This lets your instructor know that you are tailoring your care to your patient. You will see more examples of specificity as you look at the sample care plans in this manual.
Each of the interventions you plan has a corresponding rationale; a scientific explanation for why that nursing care measure is appropriate. Beginning in your second semester you will be required to list a rationale for each of your interventions. Many students find this to be a tedious and somewhat superfluous step. I urge you to examine each rationale carefully, as it is an important component of your learning. As nurses, it is essential that we understand not only how we do things, but why we do things. Rationales reflect what research has proven to be best‐practice.
Implementation is simply carrying out the interventions you have identified as being necessary for your patient’s care. Potter and Perry (2005) teaches that “preparation for implementation ensures efficient, safe, and effective nursing care” (p.344). Part of your preparation involves having a thorough care plan completed before you arrive for clinical. This is mandatory, and for good reason. How else would you know what to do with, and for, your patient? When you report for clinical, you must assess/reassess your patient in order to determine whether your planned nursing interventions are still appropriate or necessary for the patient. Implementation involves many steps including, but not limited to, direct care, counseling, teaching, and prevention of complications. A well‐thought out and comprehensive care plan guides you through these steps and helps you practice efficiently, safely, and effectively.
The final step in the nursing process, evaluation, allows us to determine whether our use of the nursing process was effective. It asks the question, “Did
the patient (or the patient’s condition/well‐being) improve”? Each nursing
diagnosis you identify has specific and measurable desired outcomes. Evaluation is based on whether the expected outcomes were achieved, and not on whether specific interventions were carried out or helpful. This is an important distinction and one you need to understand. For example, a diagnosis of Impaired Physical Mobility suggests the following outcomes:
Patient will (give specific time frame):
‐ Increase physical activity
‐ Verbalize feelings of increased strength and ability to move
‐ Demonstrate use of adaptive equipment (specify crutches, walker, etc.) to increase mobility
Now, while some of your interventions for this diagnosis will include treating the patient’s pain before activity, using a gait belt while ambulating the patient, and increasing independence of ADL’s, evaluation is not based on whether these care measures were carried out successfully. Rather, you will be evaluating whether the nursing process was effective as a whole. You will document, on your care plan, whether you believe your assessments, diagnoses, planning, and implementation measures were correct and accurate, and you will need to provide rationales to support your position. Remember that your judgments must be based on whether your patient met, or is progressing towards, the expected outcomes.
Your written evaluation is added to your care plan after you have completed your first day of clinical. Based on your assessments and evaluations, you may need to change your priorities for day two; some of your diagnoses may still be pertinent while others may need to be changed. Pay attention to this part: please resist the temptation to leave your top five priorities unchanged simply because you can get away with it! I have known some students who, because they did not want to have to “work up” another nursing diagnosis, would keep their top five in spite of the fact that changing some of them would have been more appropriate. I understand that adding more work to your care plan after having little sleep and a long day at clinical is the last thing you want to do. However, trust me when I say that doing just that contributes to your clinical education and mastery of the nursing process. If you fail to be conscientious in this area you are cheating yourself and your patients.
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