How to Create a Nursing Care Plan
Your creation of a nursing care plan follows your assessment of your patient. At this point, you have identified your patient's needs and you can incorporate them into your nursing care plan with the goal of meeting long and short-term patient goals. You will use the nursing care plan you create as a tool to assist you in your patient care evaluation.
Instructions
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1
Identify the patient diagnosis and record it in accordance with North American Nursing Diagnosis Association (NANDA) standards. Record all signs and symptoms that support the diagnosis as well as any other subjective observations that are relevant to the diagnosis.
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2
Identify specific patient outcomes based on the patient's current status. Formulate realistic long- and short-term patient outcomes. These outcomes should be specific and realistic, and should include dates. If it is unclear how fast the patient will recover, build in more time to reach the goals.
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3
Consider and record the patient's mental, emotional and physical status in relation to his long- and short-term goals as well as how you will implement the care plan. Give special consideration to when your patient lacks motivation, support and morale. This will ensure that your nursing care plan incorporates the whole person and not just the physical signs of illness or disease.
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4
Define and list the specific actions to be taken by the patient care team. Include those that are medical, pharmacological, social, behavioral and dietary in nature. They should note who is responsible to carry them out, and they should be associated with dates. Whenever possible, include the patient in the care process through educational interventions.
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Share the nursing care plan with the patient, his family and the other members of the care team. Record any objective and subjective observances that will affect the patient's potential outcome, and make adjustments as necessary.
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Tips & Warnings
Create the nursing care plan with the goal of enacting a team effort on the part of all involved parties: the patient, the family and the medical staff. This will ensure more successful patient outcomes.
