Nursing care plans include detailed instructions for the type, frequency and purpose of a patient's care. They include treatment orders, medication orders, preventative measures and orders for tests. Nurses create a care plan for each patient placed in their care. They use information collected during assessment to form a nursing diagnosis. Nurses use the nursing diagnosis to decide which nursing interventions are needed. Nursing interventions refer to the care and treatment performed by nurses.
Gather information needed to form nursing diagnoses. Ask the patient questions pertaining to their problem or symptoms. Review the patient's medical history and current medication list. Use the information to form a nursing diagnosis.
Create a nursing diagnosis. NANDA (North American Nursing Diagnosis Association) is involved in the development of medical terminology used to improve the quality of nursing care through the creation of nursing diagnoses and evidenced-based practice. Refer to the NANDA for a list of guidelines used to write nursing diagnosis statements. Write a nursing diagnostic for each problem experienced by the patient. Check each diagnosis to ensure it correct. Fix mistakes if found.
Choose the most effective nursing intervention for each symptom. This refers to the intervention that best treats, alleviates or prevents specific symptoms and conditions. For example, an effective nursing intervention for a patient suffering from a pressure ulcer on their buttocks includes alleviating pressure by using a special mattress and implementing a turn schedule.
Make a time schedule for treatments, medication administration and patient assessment. Create a medication schedule in compliance with the physician's order. If the patient is ordered diabetic medication taken twice per day, the nurse must determine what times the medicine should be taken to ensure two doses were received within a twenty-four hour period.
Add the completed nursing care plan to the patient's chart. Modify the care plan as necessary when changes in a patient's condition occur. Changes include deterioration in overall condition, difficulties or non-compliance with treatment. Adjust the care plan to include new nursing diagnostic statements and nursing interventions for any new problems that arise. Discontinue interventions when the patient's condition improves or when no longer effective.