We all learned how to write nursing diagnoses and care plans in school They started something like this:
Nursing Diagnosis: “Ineffective Breathing Patterns related to infection as evidenced by a change in respiratory pattern and tachypnea.”
Have you written a nursing diagnoses like this since you started your nursing career? Probably not, if you work on a busy unit. Even if you had the time, writing long, wordy nursing diagnoses that the rest of your nursing team might not understand seems useless in improving patient care. Here are some practical guidelines to help you write understandable, useful nursing diagnoses and nursing care plans.
1. State the nursing diagnosis using simple language. Don’t be afraid to include the medical diagnosis.
Everyone on your nursing team needs to be able to understand the patient’s problems. If the patient has pneumonia, say so.
The nursing diagnosis, “Ineffective Breathing Patterns related to infection as evidenced by a change in respiratory pattern and tachypnea.” becomes “Shortness of Breath (SOB) Secondary to Pneumonia.”
2. Write the plan backwards
If you have difficulty coming up with the goal, start with the interventions first. Then write the goal. The goal can be the opposite of the nursing diagnosis.
“No SOB” might be too short.
“Within the next 2 weeks, the patient will no longer have SOB or any other signs or symptoms of pneumonia.” is more specific about the outcome you want.
3. Say plainly what you are going to do
Your language does not have to be fancy, just understandable. “Elevate Head of the Bed (HOB) at least 30 degrees” is a clear and concise directive.
4. Eliminate obvious interventions
Don’t waste time and energy by saying the obvious like: “Follow physician’s orders to give antibiotic.”
What nurse would not give an ordered medication? Instead, use interventions that remind you what to do such as, “Watch for side effects of antibiotic such as rash, diarrhea, nausea.”
Don’t be intimidated when writing nursing care plans. You don’t have to write them the way you did in nursing school. Write them like you give report. State the problem so everyone can understand it. The goal is often the opposite of the nursing diagnosis. You know what needs to be done. Don’t be afraid to write those interventions down. If you follow these guidelines, you will find that writing the nursing diagnoses and nursing care plan will not only be easier, but will help you take more consistent care of the patients on your shift and from shift to shift.