by B Borcyk

Created on: July 06, 2010

The care plan is the written derivative of the nursing process; a document which requires nurses to think critically in order to provide the best possible care to each patient. While many institutions are pulling away from paper versions of care plans, they are still one the main focal points of nursing education due to the way they lay out nursing care.

In order to understand how to write a care plan, one must learn about the nursing process itself, which consists of: assessment, diagnosis (analysis), planning, implementation, and evaluation. This is the framework for the entire piece, which long-time nurses can eventually visualize in their minds.

Assessment includes the gathering of data. It consists of demographic information about the patient, such as his or her name, date of birth, marital status, past medical history, surgical history, and even spiritual needs. It also includes a head-to-toe assessment to determine any needs the patient may have outside of the current medical diagnosis. Some of these may include fall risks, risk for aspiration, skin breakdown, or other such potential complications.

The nurse then comes up with nursing diagnoses. To best explain the nursing diagnosis, NANDA (North American Nursing Diagnosis Association) says, “A nursing diagnosis is a clinical judgment about individual, family, or community experiences and responses to actual or potential health problems and life processes” (NANDA official website). A nursing diagnosis must be NANDA-approved and should be written in a particular format. An example of this for a patient with sickle cell crisis may be: acute pain, related to stasis of red blood cells, as evidenced by complaint of localized pain (Gulanick & Myers).

In the planning stage of care plan writing, the nurse looks at ways to care for the patient based on the nursing diagnoses. These ways of caring are called nursing interventions. For example, if the patient’s diagnosis is acute pain, the nurse may elect to reposition the patient at regular intervals or administer pain medication, per physician orders (Timby & Smith).

Either way, the nurse also must plan for patient outcomes or goals to achieve. This way, after the implementation phase, or carrying out the plan, the nurse can determine if the plan of care must be changed in any way. So, if the patient is in pain, the nurse uses a pain scale to measure the pain. Then, the nurse may elect to administer medication. The outcome may be: “Patient

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