9 Steps How to Write a Nursing Care Plan – Total Nurse Network

In the healthcare world, nurses play a big role. They help patients both medically and emotionally.

One of the main things they do is create a Nursing Care Plan (NCP). Think of the NCP as a special guide made just for each patient. This lists what the patients need and how the nurse can help.

Today, we will explain how to make a nursing care plan in nine easy steps. By following these steps, you can make sure your patients get the best care. 

Step 1: Get To Know the Patient Better

If you really want to be at the top of your game, you need to know who you are attending care. Think of it like trying to help your loved one. You may not know what’s bothering them and give advice that doesn’t help much. It’s also the same for your patients. 

You can start by collecting all information about the patient through:

  • Medical Past – past illnesses, surgeries, medicines taken, and allergies. 
  • Social and Metal Info – know where they live, their family, their job, and even their worries.
  • Environment – Are they safe where they live? Are there things around that could make them sick?

Aside from these basic things, you also need to talk to your patients. They can explain more things aside from what written in the report. Also, you can make them feel understood and in return, they can trust you more. 

Really understanding the patient means collecting all your info and talking to them with care.

Step 2: Assessment

To give your patients the best care possible, continue by assessing them. Here’s how it should go:

Physical Assessment

  • Check if the patient has any clear signs that might be sick or hurt.
  • Gently touch the parts of the patient’s body to feel for any unusual bumps. Or if they’re hot or cold. 
  • Lightly tap on their body if there are any odd sounds. 
  • Use a stethoscope to listen to three sounds: heartbeat, breathing, and stomach sounds. 
  • Get more tests. This involves lab tests, picture tests, and function tests. 

Although these are the basics, they can help you know more about writing a nursing care plan. 

Step 3: Diagnosis

Diagnosis is a very important step. But, it doesn’t mean your patient automatically has a disease. Instead, you’re looking at every single thing affecting their overall health. But how do you truly figure out what is going on?

As much as a doctor gives a medical diagnosis like a patient’s ‘flu’ or ‘broken bone’, you might be more concerned about how your patients feel. Are they tired or do they feel sad?

Also, it is very important to use a common language. You have lists like the NANDA-I list to describe your patient’s needs in the same way, no matter where they are. 

After understanding what affects them, you need to decide what to help with first. Most nurses do that through Maslow’s Hierarchy of Needs. This contains a ladder from top to bottom of what’s needed.

The bottom has the most basic things like food and sleep. The top contains feelings of success and fulfillment. You need to know which do they need most. Like if something’s more dangerous now, it’s more urgent. 

Use your knowledge and skills to know what’s going on and how you want to help. 

Step 4: Make Clear Goals

When helping someone to get better, there are some markers you need to do along the way. By this, we mean make goals: both short and long. 

Short goals are achieved quickly. For instance, after surgery, your goal is to make your patient sit up for the next two or three days. 

Long goals take a bit more time to the finish line. Going back to the surgery example, your long-term goal might be to let them move freely and do their daily tasks by themselves in six weeks.

Now for a more clear and useful goal, we can use the SMART technique:

  • S (Specific) – Be clear about what you want to happen. If you want them to move better, you can say that you want them to move better. 
  • M (Measurable) – Make sure that the progress is visible. Let’s say their pain tolerance – from a rate of ten (As really painful) to five (As in tolerable) in just a week.
  • A (Achievable) – Set goals you can meet. Consider how the person is feeling and what help they need.
  • R (Relevant) – The goals you set need to be something the person can reach. If they’re worried about pain, don’t make the goal about food. 
  • T (Time-bound) – Put a time limit. It checks if things are going well and if you are on track with the patient. 

Every goal, even the small ones, helps your patient move towards better health.

Step 5: Plan Your Process

In healthcare, it’s important to make sure each patient gets care that fits their personal needs. Planning helps nurses do this. Here’s how:

1. Use Proven Treatments

With all the health issues they have, there’s a specific treatment that can help. If a patient’s sore is not healing, maybe a special dressing proven by actual studies can help. 

2. Working with Health Experts

Remember there are a whole lot of professionals to give complete care. If your patient has diabetes, you can continuously give them medicine and check their blood sugar.

Then, a food expert can suggest a diet. While a physical therapist can recommend exercises. You can work together to help the patient get the best treatment possible. 

Step 6: Going Into Action

As you build your Nursing Care Plan, putting it into action is the main highlight. But remember, to execute this, you need to be patient. If you don’t do this right, all the planning goes to waste. Below’s what you need to do: 

1. Doing the Right Care Actions

Every patient is different so your NCP needs to be different too. Once you know what steps to take, you can slowly start them.

Remember to pay attention to any risks like health problems or the medicines they take. 

2. Teaching the Patient and Their Family

As much as you need to help your patients understand what’s happening to them. For starters, tell them about:

  • Their health problem,
  • Their treatments
  • Why they need their treatments
  • How they can get better 

Use simple words and show them pictures or demos if it helps. Having the patient’s family can help a lot especially when they go home. 

3. Writing Down What You Do and Notice

Use common forms or systems to write things down so everyone can understand.

Remember, other healthcare people might read what you write. So, be clear and update your notes if there are changes or new care actions.

Step 7: Checking Your Progress

Aside from checking on the patients, check on how well you helped them. In other words, evaluate yourself.

By chatting with patients, you can learn if you’re effectively being of help or if you need to improve on something.

Thankfully, there are also pain charts or machines to see if you are working. For example, if your patient was given medicine or pain, you might want them to rate their pain on a chart if they’re getting better and better. 

Through this, you can see if things are getting better, worse, or staying the same. Now if it doesn’t help, act quickly.

Step 8: Documentation and Communication

When you create a Nursing Care Plan (NCP), it’s not just about making it. It’s about doing it right. And for that, you need to

1. Document Everything

In healthcare, if you didn’t write it, it’s like it never happened. So writing things down shows you’re doing your job well and it’s a record that keeps track of everything. 

2. Communicate Everything

Aside from your patients and their families to know what’s happening, your doctors and fellow nurses should also know the plan. This makes you work together and you can avoid doing the same thing twice or miss something important. 

Step 9: Keep Checking the Plan Regularly

In nursing, things change a lot! Because of this, we have to keep checking and updating the plans we make for taking care of patients. 

Patients can change quickly. They might get a new health problem, feel different mentally, or have changes in their life like family issues. 

Moreover, sometimes doctors and scientists discover new things that can help patients. When these changes happen, we should change the care plan to match.

For example, if someone came to the hospital for lung problems but then got another infection, we’d need to update the plan. Or, if there’s a new medicine that works better, we should include that in the plan.

Wrapping It All Up…

The Nursing Care Plan (NCP) is not just a piece of paper. It allows you to adjust in response to a patient’s condition and help you communicate better with other professionals.

Total Nurses Network created these steps to create an effective Nursing Care Plan. You can continue to commit yourself to giving your best in patient care.