How to Make a Nursing Care plan

Create a personalized nursing care plan that provides your patient with the right treatment option while simultaneously assessing his progress. While the format that you use to create your care plan can vary depending upon your hospital or care center, it must be precise and comprehensive. In order to be effective, your nursing care plan should review your patient’s medical condition and other relevant data, assign a nursing diagnosis, create measurable goals and actions to treat him, and evaluate his condition.

Instructions

• 1

  Perform a comprehensive patient assessment. Examine your patient’s medical records to review his medical and social history, medications, any abnormal lab reports or side effects he experiences. Conduct a physical examination to assess his motor and sensory nerve functions, and observe for physical signs and symptoms of his condition.

• 2

  Review all the information that you’ve gathered, including the physical examination reports and medical records, to create a problem list as part of your nursing diagnosis. Identify factors related to the problem such as family problems and eating habits, or any potential problems that could affect your patient.

• 3

  Purchase the “NANDA-I Nursing Diagnoses: Definitions and Classifications” guide. Refer to this guide for an exhaustive list of problem statements and nursing diagnoses to help you determine the appropriate care plan for your patient. Ensure that the nursing diagnosis you select is specific to your patient's medical condition, to avoid risking misdiagnosis.

• 4

  List measurable goals and outcomes that you intend to obtain through your care plan. For instance, if your goal is to improve your patient's overall nutritional status, your outcome would be to ensure that your patient gains 5 pounds within a stipulated time frame.

• 5

  Identify and implement specific nursing orders or actions that will help you achieve the desired healthcare goals for your patient. Document your nursing orders with the time, date and specific tasks that any member of your nursing team can easily follow. Use actionable instructions such as, “place a spiral bandage on the right leg from the ankle to just beneath the knee."

• 6

  Evaluate your patient’s progress in relation to your nursing care plan goals to ascertain its effectiveness. Decide whether your care plan goals have succeeded fully or partially in order to determine whether you should terminate, continue or change them.