today we're going to learn how to write a nursing care plan a nursing care plan is an essential tool to ensure comprehensive and individualized care for each patient so click the link in the description below to gain free access to these care plan templates that you can fill in later we also offer tons of care plan examples to help guide your learning from Med surge to mental health we got you covered so the first step in creating a nursing care plan is assessment this involves Gathering both subjective and objective data so starting with subjective data this includes the patient's statements about their condition for example I've been feeling nauseous and dizzy now objective data this includes measurable information like Vital Signs lab results and physical examination findings for example a blood pressure of 140 over 90 and even a temperature of 101 remember a thorough assessment is the foundation of an effective care plan now moving on to step number two nursing diagnosis these are critical judgments about the patient's health conditions or needs a nursing diagnosis has three main components problem ideology and symptoms PES for short so the components of the nursing diagnosis starting with P for problem this identifies what is unhealthy about the patient it describes the patient's response to the health condition or life process for example acute pain next is e for ideology this identifies the factors related to the problem often referred to as related to factors it describes the possible reasons for the problem or conditions under which it developed for example related to surgical incision and very lastly is s for symptoms this list the signs and symptoms often refer to as evidence by factors it includes the objective and subjective data that signal the existence of the problem for example as evidenced by the patients's verbal reports of pain and grimacing now moving on to the types of nursing diagnosis starting with an actual diagnosis this indicates that the problem exists and is supported by defined characteristics like signs and symptoms for example acute pain related to surgical incision as evidenced by a patient's verbal reports of pain and grimacing next is the risk diagnosis this indicates that the problem doesn't actually exist yet but risk factors are present for example risk for infection related to surgical incision third is the health promotion diagnosis this indicates a patient's Readiness to improve their health and wellness for example Readiness for enhanced self-care as evidenced by Express desire to manage diabetes more effectively next we have syndrome diagnos nois this includes a cluster of diagnosises related to a certain event or situation for example H trauma syndrome related to physical assaults as evidenced by nightmares and anxiety so here are a example nursing diagnosis impaired physical Mobility related to pain and discomfort as evidenced by limited range of motion and reluctance to move now moving over to Step number three the planning the planning stage involves setting goals and desired outcomes for the patient as well as identifying appropriate nursing interventions and remember goals must be specific measurable achievable relevant and time bound the smart method for example the patient will report pain level of three or below within 24 hours now moving over to interventions these are actions that you will take to achieve the goals for example administer prescribed medication every 4 hours as needed next is Step number four the implementation implementation is where you put your plan into action this involves carrying out the nursing interventions that you have planned and speaking of actions this includes administering pain medications as prescribed educating the patient on relaxation techniques to manage pain and even assisting the patient to comfortable positioning you must ensure that you document all actions is taken to maintain a clear and accurate record and lastly is Step number five evaluation this is the final step here you will assess whether the patient's goals were met and determine the effectiveness of the interventions now with evaluation criteria we simply review the patient's response to the interventions for example the patient reports a pain level of three within 24 hours we want to modify the care plan if necessary based on the patient's progress and feedback so let's go through a quick example of a nursing care plan let's say we have a patient Mr Jones who's 68 years old he's post-operative day number two after a total knee replacement surgery so for assessment if Mr Jones says my knee hurts a lot when I try to move this is a subjective assessment because the client is saying this now for objective assessment these are things that we measure for example blood pressure 150 over 90 and and a pain level 7 out of 10 now in terms of nursing diagnosis it can include acute pain related to surgical incision as evidenced by the patients's verbal reports of pain and elevated blood pressure now moving over to planning the goal here is that the patient will report a pain level of three or below within 24 hours and for interventions administer prescribe P medications every 4 hours as needed apply ice pack to the surgical site and and educate Mr Jones on deep breathing exercises now moving over to implementation administer pain medications at 8:00 12:00 and 1600 applied ice packs for 20 minutes every 2 hours and lastly instructed the patient on deep breathing exercises to help manage the pain and lastly is evaluation for example the patient reported pain level of three at 200 hours or the patient was able to perform deep breathing exercises effectively so to wrap it up here are the key steps to writing a nursing care plan it all starts with assessment nursing diagnosis planning implementation and very lastly is evaluation by following these steps you'll ensure comprehensive and individualized care for your patients remember a well- constructed nursing care plan is your road map to effective patient care keep practicing and you'll become proficient in no time and just a reminder be sure to click this link here to get access to our free templates thanks so much for watching and I'll see you there thanks for watching did you know you can unlock beautifully handcrafted study guides packed with key points and memory tricks from all our videos plus you'll get access to over 1,200 exclusive videos not on YouTube all neatly organized by nursing school topic to make that complex nursing knowledge actually stick you'll also gain thousands of practice questions written by current professors and actual enlex writers so for access to all this and more click right up here or visit simplenursing.com and don't forget to subscribe to our YouTube channel happy studying and we'll see you in the next videos