Tips on How to Write Nursing Care Plans (NCPs)

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What is a Nursing Care Plan (NCP) Assignment?

A nursing Care Plan (NCP) is a document that records the assessment criteria, diagnosis, expected outcomes, intervention measures, rationale for the care plan, and monitoring or evaluation processes. NCP assignments are evaluation tools assigned to nursing students in an online class during the course of their studies in order to test their proficiency in writing care plans.

If you wish to become a nurse, you should become acquainted with Nursing Care Plans (NCPs). These components facilitate communication between nurses, their patients, and other healthcare professionals in order to improve patient outcomes. In essence, consistent high-quality patient care is the result of a detailed NCP. Additionally, a nursing care plan documents the care provided, which is considered necessary by health insurers and for patient medical records.

Patient care is a collaborative effort in the majority of nursing settings. Whether one nurse takes over another’s shift or multiple healthcare professionals collaborate, having a coherent care plan ensures that all involved practitioners are at par regarding the patients’ welfare. A nursing care plan encompasses all pertinent information about a patient’s diagnosis and treatment goals, relevant nursing orders including required observations and actions, and an evaluation framework. The plan should be reviewed throughout the patient’s stay to reflect any developments or new information that occur.

How to Write Nursing Care Plans Using the 6-Column Format

Nursing students usually write their nursing care plans using a 6-column format. Each column has one of the following headings (in this order):

1. Column 1: Assessment

   This is a clinical assessment of the patient and includes medical reports and diagnostic tests conducted by the healthcare provider. A detailed clinical assessment is necessary before a diagnosis can be made. The American Nurses Association states that this assessment should take into account biological, mental, social, spiritual, and economic information, and other health factors. Along with listing the diagnosis and treatment, a decent care plan will also characterize them to avoid future confusion. For instance, pneumonia is an accumulation of fluid in the lungs.

2. Column 2: Diagnosis

   This is a statement of what the patient is suffering from/problems faced. Nursing diagnoses, as defined by the North American Nursing Diagnosis Organization-International (NANDA-I), draw up a list of the patient’s health complications or situations. This method helps to identify the type of care that will be provided to the patient.

3. Column 3: Outcomes

   These are the desired goals after implementation of a nursing care plan. After a nurse has assessed the patient and formed a diagnosis, the next task is to develop short- and long-term objectives. For example, if a condition is hospitalized with acute pain due to high blood pressure, the intended result may be for the patient to begin a new medication and the pain to be managed.

4. Column 4: Intervention(s)

   These are the care management strategies implemented in order to address the issue. They should be based on evidence-based practice. This is the section of the nursing care plan that is most active. This step requires nurses will to have a guideline of how to attend to the admitted individual based on the diagnosis and intended results. It may include verifying vital signs once every hour, assessing the patient using the pain scale, and administering medication, among other things. Expect to provide a great deal of detail here, as well as times, dosages, and so on. This component of the nursing care plan will indeed be adjusted as the patient’s condition changes positively or deteriorates. Every aspect of the patient’s care is meticulously documented in the patient’s medical chart and will be applied in determining whether the patient can be discharged.

5. Column 5: Rationale

   These are justifications for choosing a particular strategy and why a nursing student thinks this is the best strategy to meet the desired outcomes. The rationale should reflect an inclusion of the patient’s interests, values, and preferences.

6. Column 6: Evaluation

   This is a documentation of how the intervention strategies effected will be assessed or monitored. All through the patient’s residence, their condition will be measured and reviewed in order to adjust the plan as needed. The assessment is used to ascertain whether or not the nursing instructions need to be changed or are comprehensive as the patient progresses toward the patient goal.

Implementing NCPs

Developing a nursing care plan is a skill that you will learn in nursing school and after employment as a Registered Nurse. The excellent thing is that you are not alone in this struggle. Numerous online resources offer formats, sample care plans, and perhaps even tutorial videos to assist you in learning the ins and outs of NCPs. There is even a NANDA app that provides access to over 300 commonly used care plans. Additionally, you can seek for NCPs based on your nursing specialty, such as pediatric or surgical nursing.  Writing nursing care plans is a critical component of a nurse’s responsibilities. The best approach is to be meticulous and accurate, as well as to make use of resources available.

Steps on How to Write a NCP in 6-Column Format

In the section below, our nursing care plan essay writing experts shall advise students on the steps on how write a NCP and what each column in a 6-column NCP format should entail. For an example on a 3-column NCP, 4-column NCP, and a 5-column NCP, refer to this guide.

1. Step One: List a Patient’s Problems

   Before a nursing student starts to write a nursing care plan, he/she should come up with a comprehensive list of problems a patient faces. These should split into two: issues that can be assessed through clinical practice or tests; and psychosocial problems that affect the patient. This is essential in providing holistic care. 

2. Step 2:  Conduct an Assessment

   The second step in writing a nursing care plan is conducting an assessment. This is also the first column in a 6-column NCP.

   In order to carry out a comprehensive assessment, the nursing student should first conduct a subjective assessment. This data is obtained from the patient’s complaint such as a narration of where he/she is feeling pain, or symptoms experienced, or particular concerns leading him or her to seek medical care.

   Secondly, a nursing student should conduct an objective assessment. This usually is obtained from the following sources:

   1. A patient’s demographic data collected such as height, weight, race, age, and gender.
   2. Documented medical history.
   3. Clinical tests and diagnostic reports such as X-rays or CT scans.
   4. Physical assessment and a recording of observable physical symptoms such as blood pressure, heart rate, breathing rate, fever/temperature, swelling, and other observable signs.

   Tips on How to Write an Assessment Column

   In order to conduct a proper assessment, a nursing student should consider the following tips on how to write an assessment column in NCP:

   1. When writing an assessment column, a student nurse should first write down subjective data found in a sub-heading and then document objective data.
   2. Each sub-heading – subjective data and objective data – should contain an itemized, numeric list in brief notes.

3. Step 3:  Diagnosis

   The third step in writing a nursing care plan is coming up with a diagnosis. This is also the second column in a 6-column NCP.

   A diagnosis is an objective judgement based on clinical data – both subjective and objective data – on what the patient suffers from. The diagnosis should aptly cover the patient’s interests and goals of seeking care.

   Tips on How to Write a Diagnosis

   In order to determine a proper diagnosis, a nursing student should consider the following tips on how to write a diagnosis column in NCP:

   1. A diagnosis should be problem-focused or risk-focused. See examples below. 
   2. A diagnosis should include the assessment criteria that guided the nurse in arriving at that conclusion. See examples below.
   3. A diagnosis is usually written in a single statement. For instance, an example of a problem-focused diagnosis is: “Impaired breathing as evidenced by swelling in the nasal passages.” On the other hand, an example of a risk-focused diagnosis is: “Risk of heart attack as evidenced by high-blood pressure and rapid palpitations.”

4. Step 4: Outcomes

   The fourth step in writing a nursing care plan is coming up with desired outcomes. This is also the third column in a 6-column NCP.

   Outcomes are what the goals that the nursing practitioner wishes to achieve after implementing various interventions/care management strategies.

   Tips on How to Write Outcomes

   In order to determine outcomes, a nursing student should consider the following tips on how to write an outcomes column in NCP:

   1. In defining desired outcomes, a nursing student should consider the desires, interests, goals, values, and preferences of the patient.
   2. As these outcomes are expected after implementing intervention measures, they are written in future tenses. For example: “After 12 hours of intervention, the patient will be able to maintain a heart rate of 75-90 bpm.”
   3. Write outcomes that are SMART ( S – Specific; M – Measurable;  A – Achievable; R – Relevant; T- Time-Bound). This ensures that outcomes follow the best advanced nursing practices; and also follow evidence-based practices.

5. Step 5: Intervention(s)

   The fifth step in writing a nursing care plan is coming up with interventions. This is also the fourth column in a 6-column NCP.

   These are the care management strategies implemented in order to address the issue. They should be based on evidence-based practice.

   Tips on How to Write Intervention Strategies

   In order to determine intervention strategies, a nursing student should consider the following tips on how to write an interventions column in NCP:

   1. Write diagnosis-specific interventions or interventions that are time-bound. For instance, diagnosis-specific interventions can include specific medication; while time-bound interventions could be implemented in each shift or every 6 hours.
   2. Interventions should be measurable. 

6. Step 6: Rationale

   The sixth step in writing a nursing care plan is defining a rationale. This is also the fifth column in a 6-column NCP.

   A rationale is a justification for choosing a particular strategy and why a nursing student thinks this is the best strategy to meet the desired outcomes. The rationale should reflect an inclusion of the patient’s interests, values, and preferences.

   Tips on How to Write a Rationale Column

   In order to define a rationale, a nursing student should consider the following tips on how to write a rationale column in NCP:

   1. Defining the rationale as to why an intervention strategy has been applied requires the nursing student to state briefly which advanced nursing practices and/or evidence-based practices are applicable.
   2. A rationale column should also state why intervention measures implemented are the best among other viable alternatives.  

7. Step 7: Evaluation

   The seventh and final step in writing a nursing care plan is coming up with interventions. This is also the sixth and last column in a 6-column NCP.

   This is a documentation of how the intervention strategies effected will be assessed or monitored

   Tips on How to Write an Evaluation Column

   In order to determine evaluation or monitoring strategies, a nursing student should consider the following tips on how to write an evaluation column in NCP:

   1. Evaluate your outcomes by stating which ones have been met successfully, which outcomes are ongoing, and which outcomes are not met/ not possible. Write “Met,” “Ongoing” or “Not Met.”
   2. Include an evaluation criteria that is time-bound and measurable. For instance,  “after 12 hours, the patient was able to breathe without the aid of a nebulizer.”

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What are Care Plan (NCP)s Used for in Nursing?

Documentation is any written or printed material that is used as a record of proof by authorized individuals. Documentation and reporting are required in nursing to ensure continuity of care. They are also a legal requirement to demonstrate the nursing care provided or not provided by a nurse. The following are the reasons for documenting nursing Care Plan (NCP)s:

• Communication
• Client Care Planning
• Auditing Health Care Organizations
• Research
• Education
• Reimbursement
• Legal documentation
• Analysis of Health Care

Nurses are essential to guaranteeing patient safety while offering direct patient care. While doctors make diagnostic and therapeutic decisions, they may devote only 30 to 45 minutes per day with even the most critically ill and admitted patient, limiting their ability to observe changes in a patient’s condition over time. Nurses are a mainstay at the bedside and interact frequently with clinicians, pharmacists, relatives, and other healthcare staff.

Moreover, nurses are critical in coordinating and communicating the patient’s symptoms to the team on a timely basis. A nurse’s role in patient safety entails surveilling patients for clinical worsening, detecting errors and near misses, comprehending care processes and innate weaknesses in some systems, recognizing and sharing changes in patient condition, and conducting innumerable other activities to guarantee patients experience excellent care. As a result, nurses must generate pertinent findings and documentation to aid in the identification and treatment processes.

Nurses are uniquely qualified to report on the quality of care delivered in hospitals. They serve as the de facto monitoring system for the care process. Nurses are closely involved in all phases of patient care due to their role as the principal bedside caregiver and mediator between clients and all other clinicians. Direct caregiving, health monitoring, psychological support for patients and their relatives, guidance with everyday tasks, collaboration among inter-professional teams, and patient education are just a few examples. Thus, nurses’ interpretations of quality are formed through a set of encounters and personal observation of care.

Why do Students Write Care Plan (NCP)s in Nursing?

Student nurses are frequently tested on how to write NCPs. Therefore, they must practice on how to write NCPs and gain sufficient knowledge on these care plans if they are to successfully pass an online nursing class. Below are reasons why students must write NCPs:

1. Reason 1: To Pass a Nursing Class

   In order to meet college requirements set for a nursing student to attain a Bachelor of Science in Nursing (BSN), Master of Science in Nursing (MSN), or Doctor of Nursing Practice (DNP), students tackle assignments requiring them to write a nursing care plan (NCP). Students must attain an excellent grade in this assignment – A or at least a “Pass.”

2. Reason 2: To Obtain Knowledge on How to Write NCPs

   Nurses must know how to write care plans as they will need the skills and know-how in a practical setting. Nonetheless, coursework in nursing is strenuous and time-consuming, which is one of the reasons why the majority of students avoid the course. Instantgrades.com is well aware of the nursing profession’s importance and the requirement for registered nurses to develop proficiency in writing NCPs. This is why we provide nursing students with nursing Care Plan (NCP) writing assistance when they lack the time to complete high-quality care plans (NCPs). Instantgrades.com collaborates with over 200+ highly-qualified and experienced modern scholars and nursing professionals. They hold BSN, MSN, or DNPs in various nursing specialties, and are registered nurses practicing in various healthcare sectors. These nursing essay writing experts have extensive experience composing nursing Care Plans (NCPs) and a thorough knowledge about what it takes to write a high-quality NCP paper.

Types of Nursing Care Plan (NCP)s 

There are several different kinds of nursing Care Plan (NCP)s. The four most common are:

1. The written report
2. The taped report
3. The verbal face-to-face report undertaken in a private setting
4. The face-to-face bedside handoff.

The written nursing report does not allow for face-to-face interaction between departing and arriving nurses; rather, it is a written account of the patient’s medical history, condition, therapies, and care plan that is typically performed behind closed doors. Additionally, the taped nursing report precludes interaction between the departing and arriving nurses. While this method is considered to be time efficient, downsides such as a nurse’s failure to understand patient data, a vague or poor audiotape recording, and obsolete or misheard facts about the patient’s present state.  The verbal report produced in a private setting allows departing and arriving nurses to interact face to face, but excludes patients and family members. Additionally, it requires more time than other forms of reporting.
Face-to-face in conjunction with using handoffs seems to be the only nursing report method that considers patients, their relatives, and both departing and arriving nurses. This category of nursing report is written at the client’s bedside and comes in a variety of formats.

In general, nurse bedside shift reports fall into two categories:

•     “Blended” handoffs
•      Face-to-face handoffs.

The “blended” bedside shift report is a two-part nursing handoff. The first half of the report is written or conducted in a private setting, while the second half is conducted face-to-face at the client’s bedside. The nurse-to-nurse face-to-face bedside shift report is conducted exclusively at the patient’s bedside.

General Writing Tips for Nursing Care Plans (NCPs)

Nursing Care Plan (NCPs) are used to document and convey patient data that supervisors and clinicians require in order to make decisions.

1. High-quality nursing care plan (NCPs) must be permanent, comprehensive, and simple to understand by users in order for the reports to be used to make the best decisions possible.
2. To write an impactful nursing care plan (NCP), a student nurse must use logic and planning to ensure that all critical aspects of the report are considered. The goal is to provide a care plan that meets the patient’s objectives. Therefore, the framework used in arriving at desired outcomes and rationale should be logical and easy to follow for any nursing practitioner.
3. Writing a high-quality nursing Care Plan (NCP) necessitates a student nurse to gain an ability to organize his or her thoughts carefully and convey them in a way that is understandable to the intended audience. To achieve this, one will require a high level of proficiency and experience in report writing in order to produce high-quality work. Without adequate knowledge and experience, a student nurse may be unable to compose a factual report and, in most cases, will be declared incompetent.

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