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.
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).
Phase 1: Assessment phase
- Collect data (subjective and objective) to identify the patient’s problem.
- Lab values
- Vital signs
- Assessment findings
- 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.