Elements of a Nursing Care Plan
- Patient Assessment
Patient assessment entails a comprehensive evaluation of both the subjective and the objective symptoms and vital signs that a patient presents with to the hospital. Nurses are responsible for taking and recording patient assessment data. The patient’s assessment relates to abilities and areas such as psychosocial, emotional, physical, cultural, cognitive, spiritual, functional, environmental, age-related, and economic(
reference).
- Nursing Diagnoses
Creating a nursing diagnosis is the second element of the nursing care plan. Nursing diagnoses are developed based on the subject and objective data collected during the process of patient assessment. Nurses must follow the North American Nursing Diagnosis Association (NANDA) when making a diagnosis that must be based on a patient’s clinical manifestation, condition, and risks.
- Anticipated goals/outcomes
Anticipated outcomes/ goals highlight patients’ both short-term and long-term goals. Some of the short-term goals that patients might be seeking to achieve would include pain reduction and an improvement of vital signs such as blood pressure and body temperature. Long-term goals would include a patient recovering from an illness within a specified time frame. It is vital to note that the goals must be directly related to the nursing diagnosis to be achievable(
reference).
- Implementation
Implementation describes a process that describes in-depth how the nursing team can achieve the outlined goals. Specific nursing interventions are usually planned based on the set goals. The implementation section outlines the specific care which the nursing teams have offered to the patient. Some of the processes of care that could be described in this section include the administration of medication, surgical procedures performed, or other care-related activities that aim at managing a patient’s health condition(
reference).
- Evaluation
Evaluation is the last part of the nursing care plan. This part usually describes how the patient has reacted and responded to the nursing interventions provided. This section also highlights how the goals were met or unmet. It is vital to note that if the set goals were not met, the plan is usually revised and if they are met, the nurse may opt to design more goals and interventions to help the patient achieve optimal health status.
- How Nursing Care Plans are Created
Nursing care plans are designed immediately after a patient is admitted to a health facility. The plan is continually updated to indicate the patient’s response to interventions applied as well as possible achievement of the set goals and expected outcomes.
