Care Plan Visual

Visual guide arrow explanation:

  • First 2-3 boxes= nursing diagnostic statement.
  • Goal should correspond with the nursing diagnosis; it should aim to manage or resolve the patient’s problem only (i.e. the nursing diagnosis)
  • Interventions should help nurse reach the goal outlined which ultimately fixes the patient’s problem.
  • Evaluate the goal not the interventions.

Full explanation:

A Guide to Nursing Care Plans for Beginners

A nursing care plan is a plan that nurses use to guide the care of patients based on the problem (nursing diagnosis) identified. Care plans encompass the 5 elements of the nursing process (ADPIE).

  1. Assessment
  2. Diagnosis
  3. Planning
  4. Implementation
  5. Evaluation

Phase 1: Assessment phase

  • Collect data (subjective and objective) to identify the patient’s problem.
  • Examples:
  1. Lab values
  2. Vital signs
  3. Assessment findings
  4. Patient statements

Phase 2: Diagnosis Phase

  • Use the data collected in the assessment phase to identify the appropriate NANDA approved nursing diagnosis
  • DO NOT use a medical diagnosis or create your own nursing diagnosis by combining 2 or more diagnoses together
  • Once you have identified the appropriate nursing diagnosis, create a diagnostic statement
    • Diagnostic statement will be 3 fold for an actual problem diagnosis i.e. nursing dx r/t cause AEB proof that diagnosis is a problem for patient
    • Diagnostic statement will be 2 fold for a risk diagnosis i.e. risk for nursing dx r/t cause
  •  Your nursing diagnosis= A NANDA approved nursing diagnosis
  •  Related to factor is the cause of the problem. It can be physical, psychological, spiritual, or situational.
  • As evidence by= your evidence that supports the fact that the nursing diagnosis is a problem for the patient. It should include the subjective or objective data collected during the assessment phase.

Phase 3: Planning Phase

v During this phase, the nurse should create a goal that will help manage or resolve the patient’s problem (the nursing diagnosis).

v Goals should be either short-term (something to be achieved by end of shift) or long-term (something to be achieved by discharge).

v Goals should be S.M.A.R.T.

  • SPECIFIC: goals should be specific to your patient and not copied verbatim from your textbook
  • MEASURABLE: have a measurable element that can be evaluated
  • ATTAINABLE: should be attainable in the time allotted
  • REALISTIC: something that the patient is actually capable of accomplishing
  • TIME FRAME: have a clear time frame that the goal should be accomplished by.

Phase 4: Implementation Phase

  • During this phase the nurse should identify interventions that would help the patient meet the goal that will ultimately resolve the patient’s problem.
  • Make sure your interventions are patient specific. For example instead of saying “Assess patient frequently for pain” state “ I will assess the patient’s pain level using the numeric pain scale every hour.
  • Ensure that you include a rationale from an evidence-based source for why the intervention selected is appropriate to help meet the goal.

i)     Example of rationale: According to Gulanick & Myers (2014), the patient’s self report of pain is the most accurate indicator of the patient’s pain experience. (p.149)

  • Need 3 interventions and 3 rationales for assigned plan of care.
  •  Interventions can be something that you assess, do, or teach.

Phase 5: Evaluation Phase

  • In this phase the nurse should evaluate whether the goal was met, not met or partially met.  State the outcome first!
  • After stating the outcome, state the process that led to the outcome (i.e. what interventions were tried? Was the patient able to participate or did they refuse to participate, etc.)
  • Lastly, state a way you could revise the care plan to make it better regardless of the outcome. This helps the student to determine other interventions that could be successful in caring for a similar patient in the future.

 Hope this is helpful. If you have any questions, please feel free to ask. 


2 Comments

Walesca Darce · 02/24/2014 at 1:41 am

I will definitely(hopefully) be asking you questions one day soon!

    Brittany · 02/24/2014 at 12:39 pm

    Yay! I will try my best to help 😊

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