There is no way around it. In nursing school you must complete multiple care plans; perfectly, detailed care plans.
What is a care plan?
A nursing care plan outlines the nursing care to be provided to an individual/family/community.
Creating a care plan for the first time will seem overwhelming to say the least.
There are many resources to help guide you. Remember, the care plan is an individual outline to nursing care. Even though some may seem repetitive, it must remain patient, family or community specific.
1. As in the Nursing Process, you must first begin with your assessment
2. Talk with your patient! This can yield more information than the chart.
3. Now, look at the available NANDAs
- Remember- What are the NURSING PROBLEMS? And how do you know? (You figure out that part by ASSESSING THE PATIENT, not by reading the medical diagnosis-this can often be tempting).
4. Now, prioritize this list of nursing problems you just created, keeping in mind that the problems that are of most threat to your patient are FIRST. Meaning, the problems if not addressed quickly could cost you your patient’s life.
EXAMPLE: NANDA- Ineffective airway clearance
5. Look for the defining characteristics or symptoms from your assessment.
EXAMPLE: Ineffective cough
6. Look for the related factors – things that CAUSE the symptoms
EXAMPLE: Impaired respiratory muscle function
*Remember the difference between OBJECTIVE and SUBJECTIVE
7. Your sentence should read something like this: NANDA diagnosis…related to…as manifested by…
Now let’s put it all together
Ineffective airway clearance related to impaired respiratory muscle function as manifested by ineffective cough.
*Don’t just throw words together. It must make sense and pertain to YOUR patient.
8. Now its time to develop your patient goals. Remember to create SMART patient goals
Specific & Individualized
What is a patient goal?
This is what is expected of the patient from effective nursing care.
So, a patient with ineffective airway clearance would/should/could have the following goals:
-Patient will maintain clear, open airways
-Patient will not show signs of dyspnea
-Patient will maintain O2 Saturation of at least 90%
*Again, these are generalized. A patient with COPD may not be able to maintain an O2 sat of 90%, in fact, this may be dangerous for this type of patient.
*Remember the Nursing Process! You must continue ongoing assessments or else how will you know if your patient is improving or not improving?
9. Determine your NURSING interventions.
* I cannot stress enough that your interventions MUST be something a NURSE would do, not what the doctor would do. Don’t forget the basics!
EXAMPLE: Assist the patient in performing coughing and breathing maneuvers.
*This is therapeutic, don’t forget about your teaching. A big part of nursing is patient, family and community teaching.
EXAMPLE: Teach coughing, breathing, and splinting techniques.
*Remember that ASSIST is not the same as TEACH. You must teach your patient first and then assist.
10. Now, actually READ your care plan! You have spent hours compiling the perfect care plan, don’t forget to read through it and enjoy your handy work!
*The format of care plans can vary from instructor to instructor; so follow the template that you have been given.
*RESEARCH, RESEARCH, RESEARCH! You can only get so much information from the patient, the family and the chart. You are not going to know everything, but by doing research, this will enable you to complete a thorough care plan that you will actually understand and learn from.
3. Almost anything can be pertinent to a patient’s medical history. This plays a huge part as to why they are in the hospital currently. This information can be found in ER notes, progress notes and speaking with the family or the patient directly. Subjective and objective information can be listed here as it is all important to the patient’s history. Notice that the history is listed in chronological order, this helps you to stay organized.
4. Pathophysiology is the foundation to your care plan. Understanding how the diagnoses are affecting your patient can help you understand even more about your patient then you thought possible. When you break down and map out the pathophisiology of everything that is going on with your patient, this can lead you to new ideas. Don’t forget the basics!
5. KHI are a great way to lay out what indicators are most important while caring for your patient and what you can do as the nurse to ensure that these key health indicators are maintained.
6. Caring for any patient includes teaching, either to the patient them self or their family. These are things that should be considered from the moment the patient is admitted until the patient is discharged. Take every opportunity to teach, listing them in your care plan will help you be accountable.
7. The patient’s current orders is a great way to lay out what “plan” is set up for this patient. Although these can change depending on the client’s condition, it is important for this to be included in your care plan as this helps paint the picture and also ensure the safety of your patient. For example, in this patient’s case hourly I&O’s are required due to his end-stage renal failure as well as CHF; I&O’s are critical. Check orders in your patient’s chart frequently.
8. Now that you are about half way through your care plan it is a good idea to start thinking about which nursing diagnosese are related to your patient. This portion is to be kept brief, but still keeping in mind to list the most significant nursing diagnoses based on what information you have obtained thus far.