nursing-care-plan

name: nursing-care-plandescription: "Draft a nursing care plan from an assessment: prioritised problems, a measurable goal for each, the nursing interventions with their rationale, and how and when each goal is evaluated. Use when asked to write a care plan, turn this assessment into a plan of care, write nursing goals, student care plan help, or update a care plan after a change. Produces a problem list in priority order, a goal, interventions and evaluation criteria for each problem, and a review date. Distinct from respite-care-plan, which is for family carers."version: 1.0.0

Nursing Care Plan

A care plan fails when its goals cannot be measured ("improve mobility") or its interventions are a list of everything a nurse might ever do. This skill builds a short plan in which each problem has one goal, a few interventions that follow from it, and a date on which someone checks whether it worked. It supports documentation and learning. Clinical decisions stay with the registered nurse and the care team.

What This Skill Produces

• A problem list in priority order with the reasoning for the order
• For each problem: the evidence from the assessment, one measurable goal, interventions with rationale, and evaluation criteria
• The patient's own goals and preferences, recorded in their words where supplied
• A review schedule and the triggers for an earlier review

Required Inputs

Ask for these if not provided:

• Care setting and the format required (local template, or a nursing-process layout)
• Assessment findings: observations, pain, mobility, nutrition, skin, continence, cognition, mood, social situation
• Diagnoses and treatments ordered by the medical team
• Risk assessments already completed (falls, pressure injury, nutrition) and their scores
• What the patient says matters to them, and any family or carer involvement
• Whether this is for practice or for a student assignment (a student plan may need a named framework and references, which the student must supply or verify)

Framework: Assess, Prioritise, Plan, Evaluate

1. State each problem as a need plus its cause plus the evidence. "Risk of pressure injury related to reduced mobility, shown by a risk score in the high band and redness over the sacrum."
2. Prioritise. Airway, breathing and circulation first; then safety risks; then pain and comfort; then function, nutrition and psychosocial needs. Say when the patient's own priority differs and include it.
3. One goal per problem, written so a colleague could tell whether it was met: what will be observed, in whom, by when.
4. Interventions follow from the goal. Three to five, each specific (what, how often, who) with a one-line rationale. Mark which need a medical or therapy order.
5. Evaluation. The measure, the date, and what happens if the goal is not met.
6. Review. A date, plus triggers: a change in condition, a new risk score, a fall, a transfer.

Output Format

Care plan: [patient identifier], [setting], [date]

What matters to the patient: [their words, or "not recorded"]

Problem 1: [short name]

• Evidence: [assessment findings]
• Goal: [measurable outcome] by [date or time]
• Interventions:
  1. [action, frequency, who]. Rationale: [why]
  2. [action]. Rationale: [why] (needs order from: [team], if applicable)
• Evaluation: [measure] on [date]. If not met: [next step]

Review: [date]. Review earlier if [triggers].

Assumptions and gaps

• [Findings assumed or not supplied]
• [The assessment that would most change this plan]

Draft for the registered nurse to check against the record and local policy.

Quality Checks

• Every problem cites evidence from the assessment supplied
• Every goal names an observable measure and a date
• Interventions are specific about frequency and who acts
• Items needing an order from another profession are marked
• The patient's stated priorities appear
• A review date and early-review triggers are present

Anti-Patterns

• Do not write goals that cannot be checked, such as "improve wellbeing".
• Do not list every possible intervention. A plan nobody can deliver is not a plan.
• Do not prescribe. Medicines, doses and treatments come from the prescriber's orders.
• Do not invent assessment findings to complete a section.
• Do not copy a plan forward unchanged after a review; state what changed.

Example Trigger Phrases

• "Write a care plan for a patient two days after a hip replacement from this assessment."
• "Turn these risk scores into nursing goals I can measure."
• "My care plan goals are too vague. Fix them."
• "Update this care plan after the patient fell last night."

Run this skill in your browser: https://mohitagw15856.github.io/pm-claude-skills/skill/nursing-care-plan.html