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A nursing care plan is simple to articulate but can be tricky for new nurses who are just stepping into professional life. A nursing care plan writing helps the staff understand the patient’s situation better through smooth communication. It also serves as a legal document to show that even when the nursing shifts change, the patient receives the same standard of care they require.
A nursing care plan can be divided into five basic steps, varying by department to department, though the main points stay the same. The steps can be:
1. Assessment: In this step, nurses collect and organize medical data, such as blood sugar levels.
2. Nursing Diagnosis: In the second step, nurses diagnose the illness by using NANDA International’s standardized terminology. Keep in mind that a nursing diagnosis is completely different from a doctor’s.
3. Planning: After diagnosis, nurses plan and set short-term and long-term goals for the patient to achieve.
4. Implementation: Just after planning, nurses get to work so their patients can achieve the established goals.
5. Evaluation: Lastly, they review and see if their goals were achieved. If so, the nurses set new goals for the future; if not, nurses change the procedure or recheck where they are lacking and try again.
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