Tips on Making A Good Nursing Care Plan
Yes, admit it. One of the struggles every nurse faces is making Nursing Care Plans. Who would ever forget those sleepless nights spent burning candles just to have something to pass on time? Or that time when you had to conduct an interview and a comprehensive assessment for the NCP? Making nursing care plans might not be one of your most favorite parts in nursing, but it is important when it comes to patient care. Here are some tips to help you make a good one:
Gather as Much Data as Possible
Believe it or not, this is one of the most important parts of the NCP. Read the patient’s chart, browse the latest diagnostic/laboratory results and note significant values affecting patient’s condition. As well as the patient’s history, medications, the current condition of the pages in the Nurses notes and the latest treatment regime on the Physicians sheet. You can get your objective signs here.
Assess your patient
This may include communicating with the patient, assessing pain levels, performing physical assessment in order to finally gather the subjective symptoms and objective signs based on your assessment such as breathing pattern, symmetry, quality and breath sounds.
Prioritization
You have to prioritize accordingly basing on the ABC’s of life. Prioritize the significant clues/cues and formulate the Nursing Diagnosis based on those as well as use the approved North American Nursing Diagnosis Association (NANDA) diagnosis that matches the signs and symptoms.
Use the NANDA
The NANDA diagnosis has guides for a long term and short term goal per Nursing Diagnosis where you will work out your Evaluation which is case specific. It usually comes with interventions and rationales for you to understand the scientific reason behind each nursing action.
Don’t just copy. Understand
Be aware that not all of the interventions listed with each corresponding Nursing Diagnosis can be done. Remember that each individual is unique done and that every patient condition and situation varies.Set goals and estimated time. Rationalize your nursing diagnosis and interventions and at the end of the intervention process, reassess the patient.
Some may overlook the importance of NCPs in nursing school, claiming that it’s just a waste of time, but always remember that everything placed in the nursing curriculum serves a specific purpose. With the correct assessment and diagnosis comes appropriate interventions that would address specific problems. Without NCPs, care would be less organized and sometimes, certain areas that need nursing attention might be overlooked.
Sources:
- http://www.nursingguide.ph/article_item-397/Writing_the_best_Nursing_Care_Plan.html
- http://www.wikihow.com/Make-a-Nursing-Care-Plan-(NCP)
Liane Clores, RN MAN
Currently an Intensive Care Unit nurse, pursuing a degree in Master of Arts in Nursing Major in Nursing Service Administration. Has been a contributor of Student Nurses Quarterly, Vox Populi, The Hillside Echo and the Voice of Nightingale publications. Other experience include: Medical-Surgical, Pediatric, Obstetric, Emergency and Recovery Room Nursing.
