A care plan is an outline of the care that is expected to be provided to a patient based on their clinical picture. A well constructed care plan consists of the following:
- a holistic approach, taking into consideration psychosocial and socioeconomic concerns
- focuses on interventions to relieve or minimize a current health problem
- has mutually set goals and parameters that are SMART (Specific, Measurable, Action-oriented, Relevant, Time-bound)
Nursing diagnoses are clinical judgments set based on a patient’s response to actual or potential health problems. The following is a typical set up of a nursing diagnosis:
(nursing diagnosis) related to (medical diagnosis or primary complaint) as evidence by (signs & symptoms)
Example: Acute pain R/T abdominal incision AEB grimacing, rating of pain 6/10.
The North American Nursing Diagnosis Association-International (NANDA-I) is the main organization for defining standard nursing diagnoses. It is important to note the different between a NURSING and a MEDICAL diagnosis.
A MEDICAL diagnosis focuses on the primary complaint, disease or illness.
A NURSING diagnosis focuses on the patient’s response to actual or potential health problems.
There are four types of nursing diagnoses as defined by NANDA-I:
- Actual diagnosis – an existing health problem
- Potential diagnosis – a “risk for” problem
- Health promotion/Wellness diagnosis – readiness to enhance well-being and self health
- Syndrome diagnosis – a cluster of nursing diagnoses that are better addressed together
In nursing school, take the time to construct these efficiently. These care plans are meant to train you to think like a nurse. What is the patient’s background? What is your plan of action? What are several nursing diagnoses you can associate with this patient? What is your priority intervention? All of these questions need to be answered once you begin your shift as an RN in the real world.