Nursing Care Plan Steps

Overview

This lecture explains how to write a nursing care plan, detailing the five essential steps and providing examples to guide practice.

Assessment: Gather subjective (patient-reported) and objective (measurable) data about the patient’s condition.
Nursing Diagnosis: Identify the patient's health problem using the PES format—Problem, Etiology, and Symptoms.
Planning: Set specific, measurable, achievable, relevant, and time-bound (SMART) goals and identify appropriate nursing interventions.
Implementation: Carry out planned nursing interventions and document all actions taken.
Evaluation: Assess if patient goals were met and modify the care plan as needed.

Actual Diagnosis: Problem exists, supported by symptoms (e.g., acute pain related to surgical incision as evidenced by pain reports).
Risk Diagnosis: Problem does not yet exist but risk factors are present (e.g., risk for infection related to surgical incision).
Health Promotion Diagnosis: Indicates desire to improve health (e.g., readiness for enhanced self-care).
Syndrome Diagnosis: Cluster of related diagnoses from a specific event (e.g., trauma syndrome from physical assault).

Assessment: Subjective—patient reports severe knee pain; Objective—BP 150/90, pain level 7/10.
Nursing Diagnosis: Acute pain related to surgical incision as evidenced by verbal pain reports and elevated BP.
Planning: Goal—patient will report pain level of three or below within 24 hours.
Interventions: Administer pain meds every 4 hours, apply ice packs, educate on deep breathing.
Implementation: Document specific times for medication, ice packs, and patient education.
Evaluation: Patient reports pain level of three and can perform deep breathing exercises.

Subjective Data — Patient’s own statements about their symptoms.
Objective Data — Measurable information like vital signs or lab results.
Nursing Diagnosis (PES) — Problem, Etiology (cause), and Symptoms.
SMART Goals — Specific, Measurable, Achievable, Relevant, Time-bound outcomes.