Hello everyone! This post is something a little bit different compared to my other posts. I wanted to share how I breezed through care plans as a nursing student. Below you will find the simple steps I took to whip up a nursing care plan. Keep reading if you are in need of some help!
Nursing care plans are easy. Yes, I said it. Let me show you why.
Okay, let’s start with the “nursing diagnosis”. I abhore this title, but anyway… The point of doing these in nursing school is to make you think about what is going in with your patient, what you expect to see and what you should expect to do as part of your interventions.
THE FORMULA
Problem → related to → Medical Etiology → as evidenced by → Signs/Symptoms
When it comes to the nursing diagnosis you have three main components you need to “fill out”.
➊ Problem
Contrary to popular belief, you do not need to overthink this. Simply find the current approved NANDA nursing diagnosis list for the year.
➋ Medical Etiology
Next, I think of this section as the “medical etiology”. What you are looking for here is the pathophysiology of a medical diagnosis. Think of it this way: You are not a physician, therefore you cannot give a patient a medical diagnosis; however, you should be able to explain said medical diagnosis.
➌ Signs/Symptoms
This is fairly self explanatory. You are literally going to list a few signs and/or symptoms that will be exhibited by the patient with said condition.
PUT IT ALL TOGETHER: EXAMPLE
Below you will find an actual example from one of my nursing school assignments in Story form. Let’s walk through it together! This example is an example of an “At Risk” diagnosis, therefore there are not signs/symptoms to list. For my former nursing program, our instructors told us if we used an “At Risk” diagnosis not to. Try to avoid using these more than once per assignment. Just keep in mind that you simply list those out for a regular diagnosis (ex: “As evidenced by chest pain, diaphoresis and anxiety”).
CARE PLAN: INTERVENTIONS
Usually, at least when I was in schoo, the final portion of your care plan consists of interventions. Round up the required number of interventions. Think “What would I do for this patient as their primary nurse?”. More than likely your instructor is looking for you to explain why you are performing the intervention and how it will benefit the patient. Please do not forget your in-text citations and reference page (APA format)! You may “know” this information, but for some reason, your instructors may want you to have reference material. The best resources to find interventions are your Medical-Surgical Nursing textbook or even the ATI books. Scan/take a picture of the pages you may need on your phone and you can whip up a care plan anytime, anywhere!
I hope this helps make nursing diagnosis and care plans easier for you! The task itself is tedious, but the concept becomes a lot easier when you approach it this way. Thanks for reading!
NURSE ANNA 