March 23, 2018

4 Steps To Writing A Nursing Care Plan

4 Steps To Writing A Nursing Care Plan

By Mariam Yazdi, BSN, RN

I know most of us feel the same way: care plans are just an excuse to keep nurses busy for the sake of being busy - as if we don't enough to do already! But if you've reached a peak in your frustration with care plans or if you're still confused about them, this article is here to help.

Keep reading if you're tired of the drab of the care plan world and want to figure out a way to piece them together like a four-piece puzzle. Let's do it!

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the WHAT

What is your patient suffering from? Or what does he have to potential to suffer from?

Now remember, this isn’t about medical diagnoses, like “aortic aneurism”, or “diabetes,” or even “hypertention.” Those are diagnoses provided by physicians; steer away from them and do yourself a favor: learn a handful of your favorite nursing diagnoses and keep them in your pocket. Use the same 5 or 6 on a rotational schedule and based on your patient’s needs because I guarantee - most people suffer from similar stuff.

the WHY

Why is your patient’s suffering from this…thing? This is the part that comes after those little words “related to” or “as evidenced by.” Here is where you can get creative and really talk about the specifics about what’s going on with your patient. Whyyyyy Spongebob?? WHYYYYYYYYYYY?

BECAUSE Mrs. Puff…

BECAUSE! It’s the answer to the why. Why is your patient at risk for the…thing? Why does your patient have…the thing? Because they are _blank_blank_blank. Because they have _blank_blank_blank.

and HOW are we going to make it better?

Here it is. You’ve made it. This is the last piece of your puzzle. This is where you let your nursing interventions shine. You’re gonna do this! and This! and This! And then of course…reevaluate. Remember ADPIE?

Now let’s put this into action.

You have a patient who fell down the stairs and has bilateral hip fractures. They are are lying in bed and have refused to change positions because it hurts so bad. WHAT are they at risk for? Risk for Impaired Skin Integrity. WHY are they at risk for it? As evidenced by unwillingness to change position…BECAUSE of (secondary to) intense pain on movement. HOW can we make it better? Control the pain, encourage gentle slight turning, change positions using the bed.

Ta Da! You did it!

As easy as that. Care plans - although sometimes tedious and frustrating on the ever mounting things we have to do - provide a roadmap to the care we give as nurses. It is written proof of the ADPIE cycle, and demonstrates to those looking in, that we are in tune with the patient’s multiple needs and are meeting them and reassessing them as they go along.

Speaking of which, my patient’s condition just changed. Now that he’s all settled - time to updated the care plan! :)

Next Up: How To Conduct a Head-To-Toe Assessment 

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