Get Help on How to Write a Nursing Care Plan

A nursing care plan (NCP) is a formal documented process that involves identifying a health care problem and selecting interventions to solve or minimize the problem. Many nursing students seek our help to write nursing care plans because they are normally too busy. A nursing care plan is based on nursing theory that is taught throughout nursing education and helps a nurse to relate the theory to nursing practice.

 

The major components of a nursing care plan are nursing diagnoses, patient problems, expected outcomes, and nursing interventions and rationales. A nursing care plan acts as a means of communication to nurses, their patients as well as other health care providers to attain desired healthcare outcomes. Our company offers the best nursing care plan writing services. We have well trained professional writers who are equipped to satisfy all your nursing care plan writing needs. Our writing services are available twenty-four hours a day to ensure we meet your writing needs.

 

1. Data Collection and Analysis

 

The first step in writing a nursing care plan is collecting data from the patient to create a patient database. The patient database includes all the health information gathered from the patient. Data used to create a patient's database involves interviews, health history of the patient, physical assessment, physical tests, and diagnostic studies. You then analyze, cluster, and organize the collected data to help you formulate a nursing diagnosis and desired outcomes.

 

 

2. Formulation of Nursing Diagnoses

 

A nursing diagnosis is a clinical judgment about the responses of an individual, family, or community to health problems or life processes. A nursing diagnosis should be formulated as described in the North American Nursing Diagnosis Association (NANDA). The three phases in formulating a diagnosis are data analysis, identification of the patient’s health problems, health risks and strengths, and formulation of diagnostic statements.

 

• Data analysis involves comparing the collected patient data against the set standards, clustering of the cues, and identifying the gaps.
• You then identify the health problems together with the client to help you identify if the problem is a medical diagnosis, a nursing diagnosis, or a collaborative problem.
• Then determine the patient's strengths, resources, and abilities to cope through the health problem. Finally, you formulate the diagnostic statements.

The nursing diagnosis has three components including the problem statement, the etiology, and the definition of characteristics. You first develop a problem statement, also referred to as the diagnostic label, to describe the patient’s health problem for which nursing therapy is given. The problem statement has two parts; the first part is the qualifier and the second part is the focus of the diagnoses. Qualifiers are words that are added to some diagnostic labels to modify the diagnostic statement while the focus of the diagnoses is the specific area addressed in the diagnostic statement.

 

The etiology component of a nursing diagnosis label identifies the possible causes of the health problems and if they contribute to the development of the problem which consequently, directs the required nursing therapy and enables the nurse to individualize the patient's care. You use the words; as related to:  to link the etiology to the problem statement. Defining characteristics are the identified signs and symptoms of the patient and are written as evidenced by in the diagnostic statement.

 

An important management tool that can be used to focus on an episode of illness is the critical pathways. Critical pathways outline the anticipated care requirements of the patient and the possible outcomes to be achieved within a pre-established period. To develop critical pathways, you could use medical diagnoses, diagnostic procedures, among others. However, critical pathways are not the standard of care for the patient. Remember, you can always hire an expert nursing care plan writer from our company if you are stuck when writing any part of the plan.

 

3. Setting Priorities and Establishing Patients Desired Outcomes

 

Once you have formulated the diagnostic statement, you then plan together with the patient which nursing diagnoses to be attended to first. The rank could be high, medium, or low in priority. Maslow’s hierarchy of needs is often used when setting priorities. Consider the patient's health values and beliefs, the resources available, and the urgency of the patient.

 

Once you have set the priorities of diagnoses, set goals for each priority you have determined. The goals indicate your expectation after implementing the nursing interventions considering the patient's diagnoses. You should have both short-term goals, and long-term goals, whereby, the short term goals indicate a change in behavior that could be achieved within a short time of hours or a few days while the long-term goals indicate an objective to be achieved over a longer duration; of weeks or even months. Both short-term and long-term goals should be valuable to the patient.

 

 

4. Nursing Interventions

 

The next step is that you choose the interventions you need to focus on to achieve the patient’s goals. The aim of nursing interventions should be to reduce or clear the etiology of the nursing diagnoses and to reduce the patient’s risk factors. Identify the nursing interventions and write them down when planning the nursing process you will actualize in the implementation stage. The interventions could be nurse prescribed (independent) interventions, physician-prescribed (dependent) interventions, or collaborative interventions. For a nursing care plan, you use the nurse prescribed interventions. The collaborative and related physician-prescribed interventions are provided as additional information at the end of the care plan. There are important things to consider when writing nursing interventions.

 

• Firstly, write the date and sign the nursing care plan. The date is important for evaluation review and future planning while your signature denotes accountability to the nursing care plan.
• Secondly, when writing a nursing intervention, start with an action verb of what the nurse is expected to do and use quantifiers to explain the planned activity. Ensure the nursing interventions are clear and specific.
• Thirdly, ensure you only use abbreviations that are accepted by the institution. Once you select the nursing interventions, you then provide the scientific explanation for choosing the nursing intervention for the nursing care plan. Scientific explanation helps to associate the scientific principles with the chosen nursing interventions.

5. Evaluation and Documentation

 

The final step in writing a nursing care plan is the evaluation or reviewing of patient’s problems and the nursing interventions, whereby, you assess the client’s progress towards achieving the desired outcomes and also assess the effectiveness of the nursing care plan. If the diagnosis is still present and the goals and nursing interventions are right you continue; if the diagnosis is still present but the goals and nursing interventions require intervention,  record it as revised; if the additional data has confirmed or ruled out a possible diagnosis, you record it as confirmed or ruled out; if the goals have been achieved and the care plan discontinued, you record it as achieved; and if a diagnosis that had been resolved has returned you record it as reinstate.

 

Once you are done with the nursing care plan you then document it according to hospital policy to form a permanent medical record for the patient, which could be reviewed in the future. In case you face any challenges when writing your NCP, you can make use of the best nursing care plan writing company at an affordable price. Contact us now via live chat or check out our Order Process page for more information.

 

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