Creativity Arise!

Visual guide arrow explanation:

• First 2-3 boxes= nursing diagnostic statement.
• Goal should correspond with the nursing diagnosis; it should aim to manage or resolve the patient’s problem only (i.e. the nursing diagnosis)
• Interventions should help nurse reach the goal outlined which ultimately fixes the patient’s problem.
• Evaluate the goal not the interventions.

Full explanation:

A Guide to Nursing Care Plans for Beginners

A nursing care plan is a plan that nurses use to guide the care of patients based on the problem (nursing diagnosis) identified. Care plans encompass the 5 elements of the nursing process (ADPIE).

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

Phase 1: Assessment phase

• Collect data (subjective and objective) to identify the patient’s problem.
• Examples:

1. Lab values
2. Vital signs
3. Assessment findings
4. Patient statements

Phase 2: Diagnosis Phase

• Use the data collected in the assessment phase to identify the appropriate NANDA approved nursing diagnosis
• DO NOT use a medical diagnosis or create your own nursing diagnosis by combining 2 or more diagnoses together
• Once you have identified the appropriate nursing diagnosis, create a diagnostic statement
  • Diagnostic statement will be 3 fold for an actual problem diagnosis i.e. nursing dx r/t cause AEB proof that diagnosis is a problem for patient
  • Diagnostic statement will be 2 fold for a risk diagnosis i.e. risk for nursing dx r/t cause
•  Your nursing diagnosis= A NANDA approved nursing diagnosis
•  Related to factor is the cause of the problem. It can be physical, psychological, spiritual, or situational.
• As evidence by= your evidence that supports the fact that the nursing diagnosis is a problem for the patient. It should include the subjective or objective data collected during the assessment phase.

Phase 3: Planning Phase

v During this phase, the nurse should create a goal that will help manage or resolve the patient’s problem (the nursing diagnosis).

v Goals should be either short-term (something to be achieved by end of shift) or long-term (something to be achieved by discharge).

v Goals should be S.M.A.R.T.

• SPECIFIC: goals should be specific to your patient and not copied verbatim from your textbook
• MEASURABLE: have a measurable element that can be evaluated
• ATTAINABLE: should be attainable in the time allotted
• REALISTIC: something that the patient is actually capable of accomplishing
• TIME FRAME: have a clear time frame that the goal should be accomplished by.

Phase 4: Implementation Phase

• During this phase the nurse should identify interventions that would help the patient meet the goal that will ultimately resolve the patient’s problem.
• Make sure your interventions are patient specific. For example instead of saying “Assess patient frequently for pain” state “ I will assess the patient’s pain level using the numeric pain scale every hour.
• Ensure that you include a rationale from an evidence-based source for why the intervention selected is appropriate to help meet the goal.

i)     Example of rationale: According to Gulanick & Myers (2014), the patient’s self report of pain is the most accurate indicator of the patient’s pain experience. (p.149)

• Need 3 interventions and 3 rationales for assigned plan of care.
•  Interventions can be something that you assess, do, or teach.

Phase 5: Evaluation Phase

• In this phase the nurse should evaluate whether the goal was met, not met or partially met.  State the outcome first!
• After stating the outcome, state the process that led to the outcome (i.e. what interventions were tried? Was the patient able to participate or did they refuse to participate, etc.)
• Lastly, state a way you could revise the care plan to make it better regardless of the outcome. This helps the student to determine other interventions that could be successful in caring for a similar patient in the future.

 Hope this is helpful. If you have any questions, please feel free to ask.