Postpartum Hemorrhage

Guide to create your Nursing Care Plan

 

Student Care Plans

Student care plans are more lengthy and detailed than care plans used by working nurses because they are a learning activity for the students.

Student nursing care plans are more detailed

Care plans by student nurses are usually required to be handwritten and have an additional column for “Rationale” or “Scientific Explanation” after the nursing interventions column. Rationales are scientific principles that explains the reasons for selecting a particular nursing interventions.

Writing a Nursing Care Plan

How do you write a nursing care plan (NCP)? Just follow the steps below to develop a care plan for your client.

Step 1: Data Collection or Assessment

The first step in writing a nursing care plan is to create a client database using assessment techniques and data collection methods (physical assessment, health history, interview, medical records review, diagnostic studies). A client database includes all the health information gathered. In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formulate a nursing diagnosis. Some agencies or nursing schools have their own assessment formats you can use.

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Step 2: Data Analysis and Organization

Now that you have information about the client’s health, analyze, cluster, and organize the data to formulate your nursing diagnosis, priorities, and desired outcomes.

Step 3: Formulating Your Nursing Diagnoses

NANDA nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses. We’ve detailed the steps on how to formulate your nursing diagnoses in this guide:  Nursing Diagnosis (NDx): Complete Guide and List for 2019

Step 4: Setting Priorities

Setting priorities is the process of establishing a preferential sequence for address nursing diagnoses and interventions. In this step, the nurse and the client begin planning which nursing diagnosis requires attention first. Diagnoses can be ranked and grouped as to having a high, medium, or low priority. Life-threatening problems should be given high priority.

Maslow’s hierarchy of needs is frequently used when setting priorities.

Client’s health values and beliefs, client’s own priorities, resources available, and urgency are some of the factors the nurse must consider when assigning priorities. Involve the client in the process to enhance cooperation.

Step 5: Establishing Client Goals and Desired Outcomes

After assigning priorities for your nursing diagnosis, the nurse and the client set goals for each determined priority. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement.

Example of goals and desired outcomes. Notice how they’re formatted/written.

One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are oftentimes used interchangeably.

Short Term and Long Term Goals

Goals and expected outcomes must be  measurable  and  client-centered.  Goals are constructed by focusing on problem prevention, resolution, and/or rehabilitation. Goals can be short term or long term. In an acute care setting, most goals are short-term since much of the nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended care facilities.

· Short-term goal – a statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days.

· Long-term goal – indicates an objective to be completed over a longer period, usually over weeks or months.

· Discharge planning – involves naming long-term goals, therefore promoting continued restorative care and problem resolution through home health, physical therapy, or various other referral sources.

Components of Goals and Desired Outcomes

Goals or desired outcome statements usually have the four components: a subject, a verb, conditions or modifiers, and criterion of desired performance.

Components of goals and desired outcomes in a nursing care plan.

· Subject. The subject is the client, any part of the client, or some attribute of the client (i.e., pulse, temperature, urinary output). That subject is often omitted in writing goals because it is assumed that the subject is the client unless indicated otherwise (family, significant other).

· Verb. The verb specifies an action the client is to perform, for example, what the client is to do, learn, or experience.

· Conditions or modifiers. These are the “what, when, where, or how” that are added to the verb to explain the circumstances under which the behavior is to be performed.

· Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These are optional.

When writing goals and desired outcomes, the nurse should follow these tips:

1. Write goals and outcomes in terms of client responses and not as activities of the nurse. Begin each goal with  “Client will […]”  help focus the goal on client behavior and responses.

2. Avoid writing goals on what the nurse hopes to accomplish, and focus on what the client will do.

3. Use observable, measurable terms for outcomes. Avoid using vague words that require interpretation or judgment of the observer.

4. Desired outcomes should be realistic for the client’s resources, capabilities, limitations, and on the designated time span of care.

5. Ensure that goals are compatible with the therapies of other professionals.

6. Ensure that each goal is derived from only one nursing diagnosis. Keeping it this way facilitates evaluation of care by ensuring that planned nursing interventions are clearly related to the diagnosis set.

7. Lastly, make sure that the client considers the goals important and values them to ensure cooperation.

Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. As for risk nursing diagnoses, interventions should focus on reducing the client’s risk factors. In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step.

Types of Nursing Interventions

Nursing interventions can be independent, dependent, or collaborative:

Types of nursing interventions in a care plan.

· Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgement and skills. Includes: ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals.

· Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest. Assessment and providing explanation while administering medical orders are also part of the dependent nursing interventions.

· Collaborative interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, dietitians, and therapists. These actions are developed in consultation with other health care professionals to gain their professional viewpoint.

Nursing interventions should be:

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· Safe and appropriate for the client’s age, health, and condition.

· Achievable with the resources and time available.

· Inline with the client’s values, culture, and beliefs.

· Inline with other therapies.

· Based on nursing knowledge and experience or knowledge from relevant sciences.

When writing nursing interventions, follow these tips:

1. Write the date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning. The nurse’s signature demonstrates accountability.

2. Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise. Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “Educate parents on how to take temperature and notify of any changes,” or “Assess urine for color, amount, odor, and turbidity.”

3. Use only abbreviations accepted by the institution.

 

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