How to Complete a Patient Plan of Care

A patient plan of care allows people in a health care setting to accurately create a map for the recovery of a patient by implementing treatments and marking short-term goals that allow both the caretakers and the patient to notice positive trends that take place. A plan of care can be difficult to complete if the diagnosis is hard to determine and the path to recovery tough to map, so you have to be extremely attentive to the needs of the patient.

Things You'll Need

• Patient, family or community response to actual or potential illness
• Complete list of approved North American Nursing Diagnosis Association (NANDA) nursing diagnoses
• Nursing Care Plan Form

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Instructions

• 1

  Identify individual, family or community response to actual or potential health problems. Once a problem is identified, formulate a long-term or discharge goal. An example statement would be: "The client will have decreased amount of fluid draining from lungs by the time of discharge."

• 2

  Select a nursing diagnosis from the list of approved NANDA nursing diagnoses, which should include what the diagnosis is "related to" and that the diagnosis is "evidenced by" subjective and objective signs and symptoms that the nurse should collect while performing the assessment.

  An example nursing diagnosis would read: "The patient exhibits excess fluid balance related to compromised regulatory mechanism as evidenced by (objective) pleural effusion, decreased hemoglobin and hematocrit, and the (subjective) client states, 'I'll be glad when this swelling goes away. I'm willing to bet I can't fit any of my clothes at home.'" This statement should also be supported with tertiary data that explains why this is a concern for the client.

• 3

  Identify client outcomes that respond to nursing interventions. The Nursing Outcomes Classification (NOC) is based on the NANDA diagnosis from Step 2. The outcome goals should be short-term goals. This is an example of a short term outcome goal: "The client will maintain clear lung sounds and display no signs of dyspnea throughout the clinical day, as evidenced by lessened amount of drainage being extracted via chest tube, oxygen saturation levels above 90 percent and no visible signs and complaints of shortness of breath."

• 4

  Select actions that the nurse should perform to assist the client in meeting the outcomes from Step 3. Nursing Interventions Classifications (NIC) are based on the related or contributing factors. The interventions should be clear, concise and purposeful. An example statement would be: "Monitor lung sounds for crackles, respiration for effort and determine the presence and severity of any dyspnea."

• 5

  Explain the rationale for all nursing interventions. If an additional source is needed, make sure to cite the source and the page number(s).

• 6

  Evaluate the client's progress toward meeting the outcome (NOC) from Step 3. The following questions and statements should be answered or evaluated for each outcome:
  Was the outcome met, not met, or partially met?
  Determine the reason(s) the outcome was not met.
  Should the outcome be continued, changed or terminated? If so, why?
  It is important to remember that if the NANDA diagnosis is terminated then outcome (NOC) and interventions (NIC) are also terminated.