One of the most common tasks done by a nursing student is writing a Nursing Care Plan (NCP). The number of Nursing Care Plans written depends on the preferences of the Clinical Instructor. Most clinical instructors or C.I.s would ask for at least one NCP at the end of a rotation. Others ask for more.
No matter how many NCPs are required from a student, the ultimate rule is that the Care Plan has to be well written. It has to deal with the patient’s most immediate need and the nursing interventions have to be effective.
What is a Nursing Care Plan?
Before going into the details of how to make an impressive Nursing Care Plan, it is important that we define it first. A Nursing Care Plan or an NCP is essentially “a Plan of Care”. It can be in bullet form or in a more popular and practical tabular form. It contains the following data:
- Patient’s Data
- Cues: Subjective and Objective
- Patient’s Needs
- Nursing Diagnosis
- Objective of Care
- Nursing Interventions
The data contained in a Nursing Care Plan varies depending on the curriculum or the nurse’s preference.
All these elements in an NCP will help a student nurse have a “road map” to his/her patient’s care.
Gather as Much Data as Possible
Data gathering is the first and most crucial step of writing an NCP. It is through this process that students come into contact with the patients. Gather as much data as you can. Check your patient’s vital signs initially. Make note of those that are abnormal and needs intervention. Listen to their verbalizations and write them down as verbatim on the subjective table of your Nursing Care Plan. Doing this step right will help you make the best NCP possible.
The NANDA Rule
The North American Nursing Diagnosis Association or the NANDA annually publishes a book of certified Nursing Diagnoses on every disease imaginable. The NANDA book is considered to be the Nursing Student’s bible. It gives nurses a set of diagnosis as well as goals and nursing interventions for each Nursing Diagnosis.
If a student wants to write a killer NCP, then he/she must have a NANDA book on hand for guidance.
Tips and Tricks
Other tips that help nursing students write a great nursing care plan include:
- Set time and date for specific goals
- Rationalize your nursing diagnosis and interventions
- Re-assess your patient at the end of your intervention process.
Again, students are reminded that standard for nursing care plan writing depends on the C.I. and the school. You, as a student must learn to be flexible to your Clinical Instructor’s wants and specifications. By doing so, you will secure for yourself good scores on your NCP.