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What is Nursing Care Plan?
A nursing care plan can be defined as a document that provides a roadmap to identifying a patient’s needs and facilitating holistic care. Besides, a nursing care plan provides communication among nurses, their patients, and other healthcare givers to attain desired patient outcomes. Therefore, without a nursing care plan, quality and consistency of patient care will not be attained.
A nursing care plan starts when the patient is admitted to a health care institution and is continuously updated in response to the patient’s changes in condition and evaluation of outcome achievement. Ideally, planning and delivering patient-centered and evidence-based care is the foundation for excellence in nursing practice and a nursing care plan makes this possible!
Types of Nursing Care Plans
A nursing care plan can either be formal or informal. An informal nursing care plan refers to the strategy of action that only exists in the nurse’s mind. A formal nursing care plan, on the other hand, refers to the care plan that is written or computerized guides that organize the patient’s care information.
Formal care plans are categorized into two categories. Standardized care plans stipulate nursing care for a group of patients with similar everyday needs. Individualized care plan, on the other hand, is designed to meet the unique needs of a particular patient or needs that are not catered by the standardized care plan.
Components of nursing care plan
The nursing care plan contains the following five main components. They include:
Assessment
This component involves collecting and analyzing data and information from the patient’s health record to gain insights and holistically understand the patient’s needs and risk factors.
Diagnosis
Using the data collected, patient feedback, and clinical judgment to come up with a nursing diagnosis.
Outcomes/Planning
This component involves setting short-term and long-term goals based on the nurse’s assessment and diagnosis and with input from the patient. this component determines the nursing interventions to achieve the desired goals.
Implementation
The implementation component entails the process of implementing nursing care as per the care plan, based on the patient’s health condition and the nursing diagnosis. Ideally, it documents care the nurse executes.
Evaluation
This component involves monitoring and documenting the patient’s health status and progress towards attainment of desired outcomes and modification of set interventions.
How it works
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3. Quality Check - Our Quality Assurance department checks the plan.
4. Plan Completed -Your nursing care plan is availed for download from your dashboard.
Writing care plans is part and parcel of the core curriculum in nursing schools. Nursing care plans offer a means of communication among nurses, their patients, and other healthcare givers to attain desired healthcare outcomes. Writing a good nursing care plan requires a step-by-step approach to complete each part of the care plan correctly.
Writing care plans doesn’t end after graduating from your nursing school. They extend into the professional world. As nurse students, you are required to write a care plan to help you focus on your patients in a holistic manner while delivering evidence-based and patient-centred care.
Equally, care plans help hospitals to ensure continuousness of patient care across nursing shifts, promote inter-professional collaboration since they get every health care provider on the same page while meeting documentation requirements for insurers and governing institutions.
As such, nursing care plans play an essential role in the treatment of patients as they clearly outline the guidelines along with the nurse’s role in patient care and help them craft a solid plan of action for desired patient outcomes.
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Why are Nursing Care Plans Important?
Nursing care plans are beneficial in health care settings in a number of ways including:
Continuity of care
Well-crafted nursing care plans allow nurses from various shifts or floors in a hospital to have the same patient data, are conscious of the patient’s nursing, share the same nursing diagnosis, and work towards attaining the same patient goals. As such, care plans serve as a communication tool for patient care between nurses and other healthcare providers.
Patient-centered Care
Nursing care plans make it possible for patients to receive evidence-based and holistic care. While nursing diagnoses are standardized to ensure the delivery of quality patient care, nursing interventions are designed to meet the physical, social and psychological needs of a patient.
Inter-professional Collaboration
Without a doubt, nurses are the core of the health care team, but they are not the only members. A healthcare team also includes physicians, nursing assistants, social workers, physical therapists among other care providers that need to comprehend the
patient’s health problems, goals, and progress. And a nursing care plan document puts together all this information and data together and provides a clear roadmap to the attainment of the desired patient outcomes.
Engage Patients
Setting attainable goals for and with patients helps to lead and measure the quality of nursing care. Besides, the goals help in motivating patients to become more involved in their recovery process since they can understand what they require to do to attain the desired outcome. A nursing care plan makes all this possible.
Compliance
Nursing care plans help nurses to uphold the nursing code of ethics and provide a record of what they did to a patient. this helps insurers determine how much they should reimburse for care or in case of accusations or lawsuits that they failed to adhere to care standards.
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How to Write a Nursing Care Plan
A nursing care plan is formal documentation of the delivery of nursing care. Nursing care plans come in different formats. Regardless of the formatting, the following steps al followed:
Step 1: Assessment
The nursing care plan begins when the nurse starts reviewing the relevant data including and not limited to medical history, lab results, vital signs, physical assessment, conversations with the patient and family members, observations from other healthcare team members, as well s demographic information. All this information and patient assessment is used to assess the patient’s risk factors, physical, emotional, psychosocial, and spiritual needs, and areas of improvement.
The assessment step of nursing care writing is essential to creating an effective and accurate care plan both for short-term and long-term care.
Step 2: Data Analysis and Organization
Now that you have gotten all the information about the patient’s health, the next step is to cluster and organize the data to create a nursing diagnosis, priorities, and the desired patient outcomes.
Step 3: Identify and Make a Diagnosis
A nursing diagnosis is different from a medical diagnosis since it is based on the patient’s response to an illness, instead of the illness itself. Basically put, a nursing diagnosis focuses on patient care rather than treatment.
Therefore, after a thorough assessment of the patient’s health problem, the nurse should identify nursing diagnoses – a health problem that they can handle without the physician’s intervention. For instance, a nursing diagnosis may be fever, insomnia, acute pain, and risk for falls.
According to the North American Nursing Diagnosis Association (NANDA), a good nursing care plan should not just list each diagnosis but go an extra mile to define it as well. For instance, acid reflux should be described as “ineffective airway clearance related to gastroesophageal reflux as evidenced by retching, upper airway congestion, and persistent coughing.”
Step 4: Setting Priorities
Once you have positively identified a diagnosis, the next thing to do is set priorities. The setting of priorities involves formulating a preferential sequence for addressing the nursing diagnosis in step 3 and the interventions you will set up. Therefore, in this step, the nurse and the patient will plan which nursing diagnosis needs to be addressed first.
Ideally, diagnoses can be ranked and categorized as having high, medium, or low priority. Certainly, life-threatening diagnoses should take the high priority rank. Moreover, a nurse can prioritize diagnoses based on Maslow’s Hierarchy of Needs. The hierarchy will help the nurse base the patient’s needs from the basic needs at the base of the pyramid to ones at the top.
In this case, the basic physiological needs or goals must be achieved before the higher goals such as self-esteem and self-actualization. Furthermore, physiological and safety need provide a basis for the implementation of the care plan as well as nursing interventions.
Step 5: Establishing Patient Goals and Desired Outcomes
Once you have assigned priorities for your nursing diagnoses, the nurse and the patient should set the goals or desired outcomes for each determined priority. Essentially, the goals or desired patient outcomes describe what the nurse endeavours to achieve by executing the nursing interventions gotten from the patient’s diagnosis.
Moreover, the desired outcomes provide leeway for planning interventions, serve as criteria for evaluating patient progress, allow the patient and nurse to determine which problems have been resolved as well as help encourage the patient and nurse by providing a sense of attainment.
NOTE: One overall outcome is determined for each nursing diagnosis. Also, keep in mind that the terms outcome, goal, and desired/expected outcome are regularly used interchangeably.
The goals you set should be:
Specific: It should be clear, concise, significant, and sensible for an outcome to be effective.
Measurable or Meaningful: Ensuring a goal is measurable makes it easier to monitor progress and know when it is achieved.
Attainable or Action-Oriented: Goals should be versatile yet remain possible.
Realistic or Result Oriented: It is necessary to look forward to effective and successful outcomes while keeping in mind the available resources available.
Timely or Time-Oriented: Every goal you set requires a designated time parameter as well as a deadline to focus on and an idea to work toward.
Short – Term and Long–Term Goals
Goals as well as desired outcomes ought to be measurable and patient-centred. Ideally, the goals are crafted by focusing on problem prevention, resolution, and rehabilitation. Care plan goals can either be short–term or long–term.
However, most goals are short–term, especially in a critical care setting because much of the nurse’s time cater to the patient’s immediate needs. On the other hand, the long–term goals are usually used, especially for patients suffering from chronic health problems or living in nursing homes, in homes, or in extended-care establishments.
What is a short-term goal? This is a statement differentiating a change in behaviour that can be attained straightaway often within hours or days.
What is a long-term goal? This is a statement indicating an objective to be completed over an extended period, often over weeks or months.
What is discharge planning? This is a process involving the naming of long-term goals thus promoting sustained curative care and problem determination via home health, physical therapy, or through different other referral sources.
Step 6: Selecting of Nursing Interventions
Nursing intervention refers to activities or actions that a nurse undertakes to attain a patient’s expected outcomes. The interventions you select should entirely focus on eliminating or alleviating the etiology of your nursing diagnosis. However, for risk nursing diagnoses, interventions should mainly focus on lessening the patient’s risk factors.
In this step, nursing interventions should be identified and written during the planning step of the nursing process and executed during the implementation step. Nursing interventions come in three varieties. Which one are they?
Types of Nursing Interventions
Nursing interventions can either be dependent, independent or collaborative;
Dependent Nursing Interventions
These are activities or actions done under the physician’s instructions or supervision. These actions may include orders to direct the nurse to give medications, treatment, diet, intravenous therapy, diagnostic tests, and rest or activity. Assessment and provision of explanation while administering medical orders are also categorized under dependent nursing interventions.
Independent Nursing Interventions
Independent nursing interventions refer to the activities that nurses are licensed to initiate based on their sound judgment and skills. These include ongoing assessment, physical care, emotional support, teaching, and making referrals to other health care specialists.
Collaborative Nursing Interventions
These refer to actions or activities that a nurse performs in collaboration with other health team members that include, doctors, dietitians, therapists, and social workers. The collaborative activities are developed in consultation with health care providers to gain their expert perspectives.
Characteristics of Nursing Interventions
The nursing interventions you develop should be:
- Safe and appropriate for the patient’s age and health condition.
- As per the patient’s values, culture, and beliefs
- As per other therapies
- Based on nursing knowledge and experience from relevant sciences
- Attainable with the available resources and time
Step 7: Providing Rationale
Rationales are the scientific explanations that explain why a specific nursing intervention was selected for a nursing care plan. Often, rationales are not included in regular hospital care plans. However, they are included to help students associate the pathophysiological and psychological principles with the chosen nursing interventions. Our nursing care plan help can deliver you high-quality and evidence-based nursing care plan rationales.
Step 8: Evaluation
In a nursing care plan, evaluation is a planned, ongoing, purposeful activity toward the patient’s progress to attaining desired outcomes and the effectiveness of the care plan. Evaluation is a necessary component of the nursing process since conclusions are drawn from the evaluation step to determine if the nursing interventions should be modified, continued, or terminated.
Conclusion: Writing an Effective Nursing Care Plan
Writing an effective nursing care plan requires active communication, goal-oriented tasks, accessibility, and shareability as well as evidence-based actions. If your care plan meets these qualities and is effectively supported by your intuition, critical thinking, and overall focus on the patient, your nursing care plan becomes a go-to resource for nursing students or any registered nurse to search and access all the information they need.
Our nursing care plan help services are up to standard with professional nursing writers to ensure nursing students get the best and most effective nursing care plans from us. Keep in mind that a care plan is your roadmap for delivering effective nursing care and a collaboration tool for improving the whole healthcare process!