01.02 How to Write a Nursing Care Plan

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Overview

  1. The Nursing Process
    1. Assess
      1. Gather data
    2. Diagnose
      1. What’s the problem?
    3. Prioritize
      1. What’s most important?
    4. Plan
      1. What can I do about it?
    5. Implement
      1. DO IT!
    6. Evaluate
      1. Did it work? How do I know?

Nursing Points

General

5 Steps to Writing a Nursing Care Plan

  1. Collect all information (Assess)
    1. What’s going on with your patient?
    2. What are your findings?
    3. What is the patient reporting?
  2. Analyze the Information (Diagnose & Prioritize)
    1. What is a problem?
    2. What needs to be improved?
    3. What is the priority?
  3. Ask How (Plan, Implement, & Evaluate)
    1. How did you know it was a problem?
    2. How would you address it?
    3. How would I know if it’s better? (goals)
  4. Translate
    1. Put it in the terms you need
      1. High-level nursing concepts
      2. NANDA / NIC / NOC
        1. Nursing Diagnosis related to cause as evidenced by data
    2. A way to concisely articulate the problem/priority and plan
  5. Transcribe
    1. Complete the form/template
      1. Don’t include unrelated/unnecessary information
    2. Make connections between associated info
      1. Problem –> Data –> Intervention –> Rationale –> Expected Outcome
      2. What’s wrong –> How do I know? –> What will I do? –> Why? –> What should I see?

Reference Links

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Video Transcript

Okay guys, in this lesson, 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 the heck do I write an appropriate nursing diagnosis, all of it. 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.  

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.

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!

First is Collect ALL information.   Guys, this is your assessment step – gather all data. Normal, abnormal, subjective, objective… all of it.  What is going on with your patient, what’s their history? What are 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.

Once you have all the data you need, you’re going to analyze it.  This is when we get to the 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 I want you to look at here is what is an actual problem versus a potential problem. Just because they have a history of hypertension doesn’t mean that coronary perfusion is an issue, right? But is it a potential problem? Sure!  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.

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 here.

So really, overall, we’ve said – What am I seeing? What’s the problem? How do I know? What can I do about it? How will I know if it worked? That’s it! That simple!

So your next step here is Translate. What this really means is that you put this 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. Now, these are copywritten, so I can’t give you specifics. But I will say that to write them, 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 really you just need to know which terminology you’re using. Now, I’ll be honest – I really HATE this aspect of forcing you to use specific words. I had a student once and I was asking her what her priorities were for her patient. She started to think really hard and was like “ummm.. impaired integrity related to….” and I stopped her – I was like “I don’t care what words you use – don’t force it – just tell me what the problem is!!”.  And she goes “well – he has ‘old man skin’!” Which was great! Who cares what words she used, really, she recognized that his skin was thin and frail and prone to tearing and lots of issues, right? So – if you do have to pick certain terminology, this is the point at which you would do that. BUT – in our opinion, it’s MORE important that you can just articulate the major issues, right? Okay… so, you’ve gotten all your information, you translated it into the terms you need…now…

It’s time to transcribe. That just means get it on paper – make it official.  The big thing to know when you start transcribing 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.

In terms of formatting, it’s really up to you on how you want to transcribe this, and you might even have a certain form or template you’re required to use for school.  But if not, then we encourage you to find a format you like. We came up with this super simple template that’s exactly the format I just talked about. You’d just go across and keep relevant data together, right? So – problem: “old man skin”, data: thin, frail skin, presence of skin tears, bruising, Interventions: turn q2, moisturize skin, lift sheet. Why: prevent pressure ulcers, prevent tears, prevent friction/shear.  Now, when it comes to outcomes – we have to think about what you’re really going to be able to accomplish – this might short term or long-term. So what might we actually see TODAY? Maybe no new skin tears? No signs of breakdown, right? So ultimately, find a format you like, but still keep it simple!

So let’s just quickly recap the 5 steps. First, collect all information – that’s your assess step. Then analyze the information – what’s the problem and what’s the priority?  Then ask your how questions so you can plan, implement, and evaluate. Once you have your plan, translate it into terms you need, just make sure you’re concise. Then, get it on paper. Use whatever form or template you need to use and get it on paper.  Especially as you’re new to clinical practice, having these things on paper will help guide your practice and help you stay focused on getting your patients what they need.

In the next lesson we’re going to talk about how to practically apply nursing care plans in clinical practice and what this will look like after you get out of school and how it happens in the daily life of a nurse.

Read more

Module 0 – Nursing Care Plans Course Introduction

Module Obstetrics (OB) & Pediatrics (Peds) Care Plans

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