Student's Guide to Creating a Care Plan

[J.Adderton, BSN, MSN]

Think of a nursing care plan as a blueprint or framework for directing nursing activities to meet patient needs. This blueprint gives a "big picture" plan for carrying out the nursing process from assessment through evaluation. Care plans also promote patient-centered care and communication throughout the healthcare team. A well-designed care plan allows the nurse to evaluate the effectiveness of the care provided.

Are you ready to build a great care plan? Here we go...

Mr. R. was admitted to the cardiac floor with a medical diagnosis of exacerbation of congestive heart failure. Mr. R. is 74 years old and presented to the emergency department with a three-day history of increasing edema in his bilateral lower extremities and profound weakness. Patient reports mobility decreased due to fatigue and edema. Bilateral lower extremities from knee down with 3+ pitting edema. Patient is short of breath with ordinary activity and requiring O2 at 2-liters by nasal cannula. Last week, patient was able to ambulate in home with minimal shortness of breath. Currently, patient states "I am just too weak to walk" and is using a bedside commode. Patient states, "not being able to get around like I used to is really bearing down on me".

Assessment

The first step in care planning is to assess the patient and gather data to determine what priority nursing care does the patient need. Assessment data includes objective data (measurable information- lab values, diagnostic tests, physical assessment) and subjective data (data from the patient's point of view- pain levels, emotions, perceptions, feelings). From the case study above, the nurse has collected the following data:

Objective Data

• Bilateral lower extremity edema
• Fatigue
• Decreasing mobility
• SOB with ordinary activity
• Oxygen dependent

Subjective data

• Patient states "I am just too weak to walk".
• Patient reports working in yard just two weeks ago
• States "Not being able to get around like I used to is really bearing down on me".

In addition to assessing the patient, the nurse also interviews the patient for additional information. After gathering all data, the nurse then determines what health problem the patient is having that needs nursing care. Although the patient is experiencing a CHF exacerbation, it is the activity intolerance that is having the greatest impact on the patient. Therefore, the nurse identifies the nursing diagnosis that would best meet the patient's needs at this time.

Diagnosis

Activity intolerance related to heart failure as evidenced by SOB with ordinary activity, patient report of being "just too weak to walk".

Take-away Tip:

If you are having difficulty identifying the priority nursing diagnosis, simply ask yourself "what problem or need is most significant to the patient at this time that needs the assistance of a nurse?". The answer to this question will be your nursing diagnosis. The nursing diagnosis may not be related to the primary diagnosis. For example, a patient is admitted with pneumonia but fell during the last shift. The patient needs the educate and implement interventions for fall risk.

Establish Measurable Outcomes

A nursing outcome evaluates the impact of nursing interventions towards the resolution of the nursing diagnosis. The S.M.A.R.T. acronym is a good way to establish measurable patient outcomes.

S  Specific, should be specific to the patient and problem

M Measurable, use simple and specific action verbs

A Attainable, Agreed Upon, the patient should agree on the desired outcomes

R Realistic, outcomes should be realistic based on patient-specific resources and willingness

T Timed, outcomes should be trackable and achieved within a realistic timeframe

Examples based on our case study:

• Patient will identify higher priority tasks during periods of activity intolerance prior to discharge.
• Patient will demonstrate three energy conservation techniques when performing activities of daily living by day 2 of hospitalization.
• Patient will share feelings regarding the experience of activity intolerance and the impact on daily life within the first 24 hours of hospitalization.

Nursing Interventions and Rationales

Nursing interventions are the nursing treatments and actions that help the patient reach the outcomes that are specific to them. The nurses uses knowledge, experience and critical thinking to identify appropriate interventions. It is important the nurse implements interventions that are grounded in evidence-based practice. Rationales provide the evidence-based practice or standard of care to support the validity of nursing interventions. Frequently, nursing faculty will require students to provide evidence-based practice references to support rationals.

Examples based on our case study:

• Instruct patient to plan priority activities for times when they have the most energy. Rationale- patient with limited energy needs to perform the most important tasks first.
• Educate patient on effective energy conservation techniques specific to assist patient in managing physical activities, including
  • Perform activities more slowly with frequent pauses for rest
  • Perform ADLs while sitting in chair
  • Avoid using energy to perform nonessential activity
  • Evaluate additional resources to assist patient at home.

Rationale- Helps to increase tolerance for priority activity and coordination with resources after discharge will help assist the patient with energy conservation in home environment.

• Encourage verbalization of feelings about activity limitations and perceptions of how it impacts everyday life.

Rationale- Increase awareness of how living with activity intolerance can be both physically and emotionally difficult.

Evaluation

Evaluation is the final step of the nursing process/care plan. The nurse gathers data to determine if the patient's condition or well-being has improved. The nurse evaluates if the patient goals and outcomes have been met or if the care plan needs to be revised. Examples based on our case study:

• Patient identified the following priority activities, prior to discharge, for periods of activity intolerance: meal preparation due to insulin therapy, morning ADLs and any scheduled doctor appointments.
• Patient identified the following energy conservation techniques, prior to discharge, during periods of activity intolerance: sit while performing ADLs, schedule doctor appointments in am when energy level highest, neighbor identified to walk dog and mow lawn.
• Within the first 24 hours of hospitalization, patient expressed fear related to worsening activity intolerance. Patient fears not returning to baseline activity level and inability to care for self. Patient verbalizes "I will lose hope if I am not able to meet with my coffee group at least weekly".

Take-away Tip:

During the evaluation phase, the evaluates if the expected goals/outcomes are met. The evaluation phase does not evaluate whether or not nursing interventions were implemented.

Conclusion

Is the process of care planning a little clearer after reading this article? There are many care plan examples and format available (online, in textbooks). If you are assigned a care plan, be sure to follow the format provided by your nursing faculty. Remember, care planning will be awkward at first, but as you use the nursing process, you will increase your confidence.

What questions about care planning can I answer for you? Any tips you would like to share with other students?