Page 14 - Advanced Communication in Nursing

b. Read the text below. Put the information from the box to the right steps according to the text.

How to Write a Nursing Care Plan

As a nurse, you must focus on the most significant problem affecting the patient. You need to consider not
only the medical problems but also the physical problems. It is simply because in some situation, concern to
patient’s psychological might be more pressing or even holding up discharge instead of the actual medical
issue.
Here are some steps to help you write your nursing care plan:
Step 1: Assessment
In this part, you are going to gather the data, both from the patient and from your observation and

measurement. The data can be the verbal statement from the patient and family, vital signs, physical
complaints, body conditions, medical history, height and weight, intake and output, patient’s feelings,
concerns and perceptions, laboratory data, and the last, diagnostic testing.
Step 2: Diagnosis
Nursing diagnosis must be chosen from what best suits the patient, the goals, and the objectives for the
patient’s hospitalization. North American Nursing Diagnosis Association (NANDA) defines a nursing diagnosis
as “a clinical judgement about the human response to health conditions/life processes. Or a vulnerability for

that response, by individual, family, group or community.” Thus, based on the chosen nursing diagnosis, the
goals to resolve the problem of the patient through the nursing implementation are determined in the next
step.
4 types of nursing diagnoses
1. Problem-focused - Patient problem present during a nursing assessment is known as a problem-
focused diagnosis

2. Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem
developing
3. Health promotion - Improve the overall well-being of an individual, family, or community
4. Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed through
the same or similar nursing interventions.
The components of a nursing diagnosis

1. Problem and its definition - Patient’s current health problem and the nursing interventions needed
to care for the patient.
2. Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed
3. Defining characteristics or risk factors - Signs and symptoms that allow for applying a specific
diagnostic label/used in the place of defining characteristics for risk nursing diagnosis
Step 3: Outcomes and Planning

Once you have determined the nursing diagnosis, the Specific, Measurable, Achievable, Relevant, and Time-

Bound (SMART) goal is created. You need to consider the patient’s medical diagnosis, overall condition, and
all of the collected data. You need to remember that a medical diagnosis does not change even when the
condition is resolved. Thus, it remains part of the patient’s health history forever.

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