How to Write a Care Plan That Doesn't Suck
Care plan structure, NANDA diagnoses, picking the right one, prioritization.
Care plans feel busywork but they teach clinical reasoning. Done right, they get faster.
Structure
Nursing diagnosis (NANDA-approved). Related to (cause). As evidenced by (objective/subjective data). Goal (SMART, specific, measurable, achievable, relevant, time-bound). Interventions (3-5, with rationales). Evaluation.
Picking the right diagnosis
Don't pick the medical diagnosis. Nursing dx focuses on patient response. Example: medical dx is 'pneumonia'; nursing dx could be 'Impaired Gas Exchange r/t alveolar inflammation AEB SpO2 88% on RA and tachypnea.'
Prioritization
Use ABCs or Maslow. Airway/breathing problems first. Then circulation. Then safety. Then psychosocial.
Common dx categories
Pain. Impaired gas exchange. Risk for infection. Activity intolerance. Anxiety. Risk for falls. Imbalanced nutrition. Knowledge deficit.
Frequently asked
Risk for vs actual?
Actual: problem present. Risk for: problem hasn't happened but probable. Both valid; pick based on patient.
How many care plans for an exam?
Programs vary. Master one solid template; adapt for any patient.
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