How to Write Nursing Care Plan

How to Write Nursing Care Plan

How to write nursing care Plan is a very key feature for a nurse and a nurse should be as much talented that she/he can make a nursing care plan easily. Nursing care plan is a set of actions, used to determine, plan, implement amd evaluate nursing care. Nursing Process is the crucial part of nursing services for patients receiving nursing care. Nursing process is a systematic organised, method of planning and providing quality  and individualized care. It's a also known as weekly care plan, actually a nurse work with a patient by making plan of care for a week or month and so on. But in general patient there is no need to plan a care for one or two month because normally a general medical-department patient get cure within few days or week and get discharge from hospital.
How to Write Nursing Care Plan
How to Write Nursing Care Plan

So a nurse or students nurse Write a plan of care called nursing care plan or weekly care plan. There is also day care plan in which a nurse prepare a plan for care for one days only, like day care centre or OPD patients.

Essential Points while writing a nursing care plan

How to Write Nursing Care Plan
How to Write Nursing Care Plan

01 Firstly a Nursing care plan should be Purpose Oriented :

Before writing a care plan we must know that purpose of nursing process is to help the nurse to manage each patient's nursing care, intelligently, scientifically, and judiciously. 

02 It must be Problem Oriented : 

Nursing process always focussing on patient's problem. Problem may be current/actual problem or potential problem.
(a) - Actual/Current problem:
Actual or current problem means actually a patient presently suffering and eg. Loss of appetite, leg pain chest pain, breathing difficulty. etc. And
(b) - Potential Problem:
Potential problems means a patient is at risk to develop problem in future like bed ridden patients is highly risk for bed sore or pressure sore.

03 It must be Goal Oriented:

While Nursing care plan a nurse keep in mind that a nurse's goal is --- to promote health.To alleviate suffering.
To prevent complications
To help in recover or restoration.

04 It must be Client Oriented: 

It means every and each steps should be taken with client centred approach.

How to start Writing Nursing care plan

By keeping in mind all about above mentioned there is mainly 5 inter-related steps in Nursing process that are as follows:

How to Write Nursing Care Plan
How to Write Nursing Care Plan

  1. Nursing assessment.
  2. Nursing Goal.
  3. Nursing Diagnosis.
  4. Nursing planning..
  5. Nursing Implementation.
  6. Nursing Evaluation
These are the steps in which all the setup of nursing care are covered up there is no need do other things in Nursing care 

Nursing assessment: 

In which 2 types of data are taken that is subjective data or objective.. subjective data means a nurse a ask the patient about their problems and suffering and recorded that data for further step and objective data means a nurse observed through assessment by various is important that How to write nursing care Plan for good assessment.

Nursing Diagnosis : 

after assessment and gatherig of data by subjective and objective data a nurse confirm a nursing diagnosis and takes further steps  according to nursing diagnosis.
There is three types of nursing diagnosis that are as:
01 one way Nursing diagnosis: eg- chest pain due to angina
02 two way Nursing diagnosis: eg- chest pain due to angina related to decrease cardiac perfusion.
03 three way nursing diagnosis: eg-- chest pain due to angina related to decrease cardiac tissue perfusion as evidence by facial expressions, verbalization, and pain scale monitor.
How to Write Nursing Care Plan
How to Write Nursing Care Plan

Parts of Nursing Diagnosis:
01 head
02 Body
03 Tails

How to Write Nursing Care Plan
How to Write Nursing Care Plan

Nursing Goal :

After that a nurse put a goal to achieve by this nursing care plan or Nursing care. In other words nursing goal are the objective which are set-out to work or steps towards accomplished that objective or goal. It is essential that How to write nursing care Plan and how not to included any other topic that not makes any difference.

Nursing planning : 

In which a nurse take appropriate step according to nursing diagnosis and current problem to alleviate suffering. In which a set of rationalized steps are chosen.


in this phase chosen appropriate rationalized steps are implemented in patients.

Evaluation :

This is final step in Nursing process in which implemented steps are analysed and scrutinized to know the improvement of patients health.

Factors To be Kept in Mind While Preparing Nursing Care Plan

It is the main factor that How to write nursing care Plan to implement every good quality in patient care.that should be maintained.
01 First assessment should be done very clearly and carefully because sometimes patients hide there problem he/she doesn't want to share their problems it's not because of he/she doesn't wanted to take treatment but it may be for some other reasons like. 
  • They think and scared if I share my problem then I have to take a another hurting methods of treatment like IM injection or any invasive procedure.
  • Sometimes they don't want to stay in hospital anymore because hospital environment is strange and lonely and. 
  • Sometime they think that staying in hospital is very expansive because they belonged to low socioeconomic class.
  • So we should do complete assessment as head to toe examination by physical examination. And record subjective and objective data.
02 Next, Nursing Diagnosis  according to finding of assessment, set a nursing diagnosis here a students nurse always do mistake by confused with medical diagnosis and Nursing diagnosis so here we need to know what is nursing diagnosis and how to make this and why it is difference from medical diagnosis.
So nursing diagnosis is the statement based diagnosis, of patients suffering in real symptomatic and actual Problem by due to  impact of medical diagnosis.
In short, nursing diagnosis is the problem of patients a nurse find out by Nursing techniques and classifies and giving statement as sentence or short paragraph. In other words any symptomatic problems that are found by nursing assessment that is mainly occur by medical problems or diagnosed disease.  now how to make nursing diagnosis
So there it is made by taking assessment and their findings. Nursing diagnosis is Presented in a clear statement in which head body tail parts are play a role.

  • Head portion says what are the actual problem found or what is patient complaint. 
  • Body portion say that what the reason that a head portion or a problem are occurring and. 
  • Tails portion say that whether is problem genuine or not and how much degree or level a problem is being occurs.

03 Here is next Nursing Goal, After Nursing diagnosis we will go for set out a goal to work toward it or give Nursing care or take steps to achieve this goal. So how to set a Nursing goal : here are some tips -when we confirmed Nursing diagnosis. Then we find out the goal from nursing diagnosis. Means we set a goal that is more essential than other like if a patient having leg pain and in the same time having breathing problems then our first goal is, to maintain breathing function because breathing problems is more important than leg pain. So, in other words goal is the objective of nursing step it decide what to do ahead.

04 Next we will go for planning  we plan by keeping in mind of nursing goal.

05 Next implementation in which the most important necessary care are given first. In which various nursing care are given as rationalized quality care are provided in which different methods of medical treatment are also given for overcome that suffering or problems.

05 Next we move to rational care in which rationals of implemented methods or care are mentioned. Means whatever nursing care are given that should have be a special rational point without rationalized a nurainu care never be correct, that's why nursing care is also called rationalized care.

06 At last, we Evaluate the health status of patients after whole steps of nursing care was given. If there is not improve than reassess the degree of health problems and replan the nursing step set a goal and give another Nursing steps to improve health of patients than re-evaluate the health status of patients.

Finale Words : 

So guys How to write nursing care Plan this is my articles a short description of all about nursing care plans. I hope guys you will find helpful tips and you satisfied with this article then support us comments us and share your idea and opinions. thankyou...!
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