How to Write a Nursing Care Plan Using ADPIE
A nursing care plan applies the nursing process to one patient. Working through it in order, from assessment to evaluation, is the best way to keep the plan logical and individualised.
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Assessment
Gather subjective and objective data. The care plan should only contain problems you can support with that data.
Diagnosis
Group related findings and name the nursing problem using the diagnosis list your program or facility approves, written in problem, etiology and signs format.
Planning
Write goals that are specific, measurable, achievable, relevant and time-bound. 'Patient will report pain of 3/10 or less within one hour of analgesia' can be evaluated. 'Patient will be comfortable' cannot.
Implementation
List nursing interventions with a rationale for each. Rationales should explain why the intervention works for this problem, ideally supported by a current reference.
Evaluation
Compare the outcome with the goal: met, partly met or not met. If not met, revise the diagnosis, the goal or the interventions.
Common student mistakes
- Listing medical diagnoses instead of nursing diagnoses
- Goals that describe the nurse's actions rather than patient outcomes
- Rationales copied without a source
- Too many diagnoses with too little depth