How to Write a Nursing Care Plan

Then the next step is to ask your how questions. These questions are going to help you with your plan, implement, and evaluate phases.  You can ask how did I know this was a problem - this is where you start really linking the pieces of data together. Which assessment findings were significant enough to tell you there’s a problem - how did you know?  Then you can ask how would you address it? What needs to be done about it? This is where you start building your interventions. Then, ask yourself - how would I know if this got better? How will I know if my interventions worked? This is how you think through the evaluate stage and you can even start to set your expected outcomes or your patient goals here.

So really, overall, we’ve said - What am I seeing? What’s the problem? How do I know? What can I do about it? How will I know if it worked? That’s it! That simple!

So your next step here is Translate. What this really means is that you put this information you just gathered into the terms you need. Some programs will use Nursing Concepts, which are just high level categories like perfusion, oxygenation, infection control, etc.  Other programs are using NANDA nursing diagnoses and the NIC and NOC terminology. Now, these are copywritten, so I can’t give you specifics. But I will say that to write them, you want to write the nursing diagnosis you chose, related to whatever is causing it, as evidenced by the data that tells you it’s a problem. So really you just need to know which terminology you’re using. Now, I’ll be honest - I really HATE this aspect of forcing you to use specific words. I had a student once and I was asking her what her priorities were for her patient. She started to think really hard and was like “ummm.. impaired integrity related to….” and I stopped her - I was like “I don’t care what words you use - don’t force it - just tell me what the problem is!!”.  And she goes “well - he has ‘old man skin’!” Which was great! Who cares what words she used, really, she recognized that his skin was thin and frail and prone to tearing and lots of issues, right? So - if you do have to pick certain terminology, this is the point at which you would do that. BUT - in our opinion, it’s MORE important that you can just articulate the major issues, right? Okay… so, you’ve gotten all your information, you translated it into the terms you need...now...

It’s time to transcribe. That just means get it on paper - make it official.  The big thing to know when you start transcribing your plan onto paper is don’t include any information that’s unrelated or unnecessary. Just include the things that are applicable to the problem you’re talking about. The other thing you’ll want to do is make connections between all the associated information. So you’ll write the problem you identified - or the nursing diagnosis, or concept, whatever it is - then you’ll want to include the data that told you that was an issue, the interventions you chose and the rationale, and then what your expected outcome is.  But again, let’s simplify this - you want to write down what’s wrong, how you know it’s wrong, what you’re going to do about it and why, and what you’re expecting to see! That’s it! That’s all a nursing care plan really is.

In terms of formatting, it’s really up to you on how you want to transcribe this, and you might even have a certain form or template you’re required to use for school.  But if not, then we encourage you to find a format you like. We came up with this super simple template that’s exactly the format I just talked about. You’d just go across and keep relevant data together, right? So - problem: “old man skin”, data: thin, frail skin, presence of skin tears, bruising, Interventions: turn q2, moisturize skin, lift sheet. Why: prevent pressure ulcers, prevent tears, prevent friction/shear.  Now, when it comes to outcomes - we have to think about what you’re really going to be able to accomplish - this might short term or long-term. So what might we actually see TODAY? Maybe no new skin tears? No signs of breakdown, right? So ultimately, find a format you like, but still keep it simple!

So let’s just quickly recap the 5 steps. First, collect all information - that’s your assess step. Then analyze the information - what’s the problem and what’s the priority?  Then ask your how questions so you can plan, implement, and evaluate. Once you have your plan, translate it into terms you need, just make sure you’re concise. Then, get it on paper. Use whatever form or template you need to use and get it on paper.  Especially as you’re new to clinical practice, having these things on paper will help guide your practice and help you stay focused on getting your patients what they need.

In the next lesson we’re going to talk about how to practically apply nursing care plans in clinical practice and what this will look like after you get out of school and how it happens in the daily life of a nurse.