According to the National Library of Medicine, Ida Jean Orlando first initiated this nursing care process in 1958 due to a lack of knowledge in nurses to implement the care process. 

If you are a new grad nurse, you probably would be wondering how to prepare a nursing care plan? Don't worry; we've got you. But first, you need to understand what a nursing care plan is?

A nursing care plan is the second step in the nursing process. A care plan outlines the nursing care to be provided to a patient. It is individualized to each patient. The care plan identifies actual and potential problems, lists goals and outcomes of care, and includes specific interventions to achieve those outcomes.

The purpose of a nursing care plan is to identify needs, establish goals, and document the process of providing nursing care.

Nurses are essential in the provision of healthcare. They play various roles in ensuring that patients receive quality care.

One of the most critical tasks of nurses is to develop nursing care plans. A well-developed nursing care plan ensures that all aspects of a patient's care are accounted for. 

This blog post will outline the steps you need to create an effective nursing care plan.

What Is A Nursing Care Plan?

A nursing care plan (NCP) is a written plan of action that is individualized and designed by the nurse to meet the patient's medical needs. The nursing care plan is based on the patient's health status and history. It is based on the nursing diagnosis, which is determined by assessing and observing the patient.

Steps To Develop A Nursing Care Plan

Preparing NCP is crucial; follow the below-mentioned steps to prepare a nursing care plan successfully.

1. Identify Client Problems

Identifying the problem is the first step to developing a care plan. The process starts with data collection. You can collect data about the client using various methods like observation, interview, or review of medical records.

If you need to know more about how your patient responds to day-to-day living, observation can help you determine their strengths and weaknesses. An interview will allow you to obtain information from your patient directly about the health concerns that affect them.

Medical records give you insight into what has happened in the past or what is currently happening with your patient.

2. Identify and List Nursing Diagnosis

Abraham Maslow in 1943 developed a hierarchy of needs to compensate for the innate lack of each individual. The famous hierarchy of needs is a theory in psychology that explains the needs of a human and it's usually depicted as an ordered list with five levels.

A nursing diagnosis should encompass these hierarchy needs to prioritize the plan care for a patient. Nursing diagnoses are developed using the NANDA nursing care plan example, which stands for North American Nursing Diagnosis Association International.

A nursing diagnosis is a clinical judgment about a specific problem or condition that a patient is experiencing. It is a statement about the problem that you can use to guide nursing care. Nurses use nursing diagnoses to develop individualized care plans for their patients.

There are many different types of nursing diagnoses. Some of the most common ones include:

• Acute pain
• Activity intolerance
• Anxiety
• Impaired skin integrity
• Impaired urinary elimination
• Risk for infection

You must first determine the illness and learn about its risk factors, signs, and symptoms and then move forward to the goals of care.

3. Data Analysis

After reviewing all data relevant to the patient's condition, the nurse analyzes it in this section. 

The analysis involves finding patterns and making connections between subjective and objective data to form conclusions about a patient's health condition. 

For example, a nurse might learn that a patient has hypertension based on their blood pressure readings.

4. Determine The Goals of Care

After identifying the client's problems, the next step is to determine the care goals. The objectives of care are the desired outcomes that you want to achieve for your patient.

According to Hamilton and Price (2013), They should be SMART, that is, specific, measurable, achievable, relevant, and time-bound.

Some examples of goals of care include:

• The patient will report a decrease in pain level from an 8 out of 10 to a 4 out of 10 within one week.
• The patient will ambulate 50 feet without assistance within two days.
• The patient will verbalize an understanding of their disease process and medications within one week.

5. Nursing Interventions

Nursing interventions are the actions that nurses take to help treat patient conditions. 

Nursing diagnosis and nursing interventions go hand-in-hand in a nursing care plan: a nursing diagnosis is made based on data collected during the nursing assessment, which helps the nurse determine what goals they should set for the patient. 

The nursing interventions are then designed to help meet those goals. Nursing interventions are what nurses do to help patients--whether it's building their strength, alleviating their pain, or providing counseling and education.

Common nursing interventions include:

• Pain management.
• Administering medications and treatments.
• Patient education.
• Recording vital signs and other information about a patient's condition.
• Coordinating care with other healthcare providers like physicians or assistants.
• Facilitating group activities with other healthcare providers and patients.

6. Evaluate The Patient's Progress

Once you have developed the plan, you can evaluate how well your care is working and whether your initial goals are realistic.

When reviewing your plan:

• Re-evaluate your goals to see if they are still realistic. Are there other specialty nurses in the hospital who can help with care? Is there someone else who can help meet a patient's needs? Do specific tasks need to be adjusted? What other support is available?

• Review your progress to see if you are on track. If issues arise, consider adding new steps or modifying existing ones to fit the patient's changing needs.

Evaluating a nursing care plan takes honest self-reflection about what is working and what isn't. Don't be too hard on yourself if you haven't achieved all of your goals yet—caregiving and meeting patients' needs might take time and  definitely needs patience from both healthcare professionals and patients!

Different Types Of Care Plans

Nursing care plans are written documents that outline the nursing care provided to a patient. They serve as a guide for nurses and can also be used as a tool to help assess and track the patient's progress. There are several different types of nursing care plans, each of which is designed for a specific purpose. The most common include:

1) Medical Care Plan - This type of care plan lays out a patient's specific medical needs and outlines the steps that need to be taken to ensure the patient receives the best possible medical care.

2) Nursing Home Care Plan - This type of care plan helps to ensure that a nursing home resident receives appropriate and timely medical treatment tailored to their needs and health status.

3) Home Health Care Plan - A home health care plan is designed to help chronically ill or disabled people live as comfortably as possible in their own homes. 

4) Hospice Care Plan - A hospice care program is intended for persons dying of a terminal illness and requires attention to their emotional and spiritual needs.

5) Rehabilitation Care Plan - A rehabilitation care plan is designed for patients injured or recovering from surgery.

6) Palliative Care Plan - A palliative care plan is designed to relieve the symptoms of a severe illness, even if the underlying cause cannot be cured.

Take Away Points!

Now we are going to summarize the key points discussed during our time together.

• It would be best to individualize your nursing care plan for your patient.
• A suitable care plan starts with a thorough assessment and analysis.
• Ensure that your goals are SMART and easily measurable.
• Find out what is essential to the patient and use this information to set consistent expectations and outcomes.
• Collaborate with other healthcare professionals when setting goals or determining an intervention.

Still on the fence? Review the book Nursing Care Plans: Diagnoses, Interventions, and Outcomes for better nursing care plans examples.

To Summarize - How To Create A Nursing Care Plan

Now you probably know how to prepare a nursing care plan. There are a variety of nursing care plans that you can put into place to meet the needs of patients. It is vital for nurses to have a strong understanding of how to create and implement these plans in order to provide the best possible care for their patients.

In this article, we've provided some tips on how to prepare a nursing care plan so that nurses can be sure they are providing the best possible care for their patients.

FAQs

1. What is the difference between a nursing diagnosis and a medical diagnosis?

A nursing diagnosis is a problem that nurses can address, while a medical diagnosis is a problem that a physician must address. 

Nursing diagnoses are often more specific than medical diagnoses, and they focus on the patient's response to the problem rather than the problem itself. 

Medical diagnoses are usually more general, focusing on the underlying cause of the problem.

2. What is the purpose of a nursing care plan?

A nursing care plan aims to provide a framework for delivering nursing care. It helps nurses organize and prioritize care and communicate their goals to other members of the healthcare team. 

A care plan also provides a record of the care that has been provided and can be used to evaluate the effectiveness of the care.

3. What is the care planning cycle?

The care planning cycle is a process that helps to ensure that patients receive high-quality, individualized care. The cycle begins with an assessment of the patient's needs and goals. Based on this assessment, a care plan is developed. 

The care plan is then implemented, and the patient's progress is monitored. Finally, the care plan is evaluated to ensure that it still meets the patient's needs. The care planning cycle is vital for ensuring that patients receive the best possible care.

4. What is the rationale in the nursing care plan?

The rationale in a nursing care plan is the explanation of why a particular intervention or treatment was chosen. It includes a detailed description of the patient's condition, the goals of care, and the reasoning behind the selected interventions.

5. Are nursing care plans still relevant?

Within the context of institutional settings, for example, in acute care hospitals and long-term residential care facilities, nursing care plans are essential.

They allow a means of planning and documenting nursing diagnoses, goals/objectives, interventions/treatment plans, monitoring parameters (vital signs, eating habits), assessment data (weighing).

However, care plans may not be as relevant within community health nursing. This is because community health nurses often work with clients who have chronic health problems and are more likely to have a team of health care professionals working with them. 

In this case, the community health nurse may be more focused on providing education and support to the client and their caregivers rather than writing a detailed care plan.

That said, all nurses should be familiar with the process of creating a care plan as it is a valuable tool for organizing thoughts and developing a plan of action.

6. How often should nursing care plans be updated?

There is no universal answer to this question, as the frequency with which nursing care plans should be updated depends on several factors. These include the individual needs of the patient, the severity of their condition, and any changes in their condition or treatment regimen.

However, it is advisable to update nursing care plans at least every week. This ensures that all care team members are aware of any changes in the patient's condition or treatment plan and can make necessary adjustments.