How to Make a Nursing Care plan

In the health care setting, patients present with health problems that are complicated by other health problems they have at the same time. Providing adequate care for these patients is the resposibilty of the health care staff taking care of them. The registered nurse is part of the health care staff and she uses care plans to map out how she will care for the patients she is taking care of.

Things You'll Need

• Paper
• Pen
• Fundamentals of nursing text book

Instructions

1. Assess your patient.

   Interview your patient about his current and past health problems. Collect information about his past family history. That is, find out what types of diseases run in his family. Ask him about his living siuation, if he has a home and people to care for him while he is sick. Perform a physical examination on him and review his medical records.

2. Identify Problems

   Study the information you gathered from your patient, physical assessment and the medical records of your patient. Look for information that shows limited or impaired body function and mental or emotional disturbances. From these bits of information, write down actual or potential problems that your client may have and the factors that are causing or contributing to these problems.

3. Write down Nursing Diagnoses

   Consult the NANDA-I in your fundamentals text book. This is a list of all the international nursing diagnoses that every proffesional nurse must use to write nursing diagnoses. Select the nursing diagnoses that best describes the problems that you identified. Write down the nursing diagnoses and then attach them to whatever is causing them with the statement "related to".

4. Goals.

   Write down what your goals for your client will be based on the nursing diagnoses that you have written down. Your goals should be realistic and focused on solving your clients problems through nursing interventions. They should also be measurable so you can check to see if you have reached them or not.

5. Nursing Interventions

   For each goal that you wrote, write down things you can do for your patient to make sure he reaches that goal.Now, do the same for all the nursing diagnoses you have. Next, do all these things you have written down for your patient.

6. Evaluation

   Review your goals and your clients condition after doing all the interventions you planned. If your client reached all the goals that you set for him, then your care plan has been successful. If however he did not meet some or all of your goals, then you need to assess your patient again. Write down evaluation statements stating if your client met the goals you set for him or not.

Tips & Warnings

• Collect as much information about your client as possible

• Use NANDA-I nursing diagnoses only

Resources

• Review courses for student nurses