Writing a Nursing Care Plan

Writing a Nursing Care Plan

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Step 1 – Collect Information

• Get information from all sources together
  • Your head to toe assessment
  • Conversations with patient and loved ones
  • Observations (lab values, vital signs)
  • Report (or your report sheet)
  • Chart review and notes
  • Discussions with health care team members

Step 2 – Analyze

• Look at all information
• What are areas in which this patient has trouble and therefore needs to progress in?
• Think about the ways you could see the patient improving and how you would know they were improving
• Write down the general issues, how you’d help them progress in that area, and how’d you’d know they were progressing

(Tip – don’t worry about writing it in perfect NANDA-I, NIC or NOC terminology… just write it down in as you think of it)

Step 3 – Think About How

• Think about how you knew these were issues
  • How did you know he was in pain? Did he tell you? Did you observe it? Was he getting pain medications?
• Look at each “how” and decide if it is subjective (is this pain or something the patient told you about?) or objective (did you gather this info with your 5 senses?)
  • Write an S or an O next to them
• What could these issues be related to?
  • A recent surgery, trauma, or disease process?
• Write all of your reasons (again in layman terms) under the problem(s) you’ve identified
• What would you do to make this better? (Interventions)
• How would you know it got better? (Evaluation)

Step 4 – Translate

• Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
• Look up the official terms for the problem(s) and write them down
• Look up outcomes and interventions that may align with what you wrote down

Step 5 – Transcribe

• Get your template out (the NRSNG Care Plan Template might help)
• Put the pieces together (problem + related to factor(s) + defining characteristics/”hows”)
• Create your nursing diagnosis
  • Use your S’s and O’s to place your subjective and objective data
• Write out your interventions and outcomes/evaluation
• Put your feet up – you’re done!