In the recent past, the nurses and the nursing sector in general have been through a lot, from staff shortages to unique hazards. As a result, becoming a certified nurse requires extensive education and passing many examinations. A crucial part of this training involves becoming familiar with nursing care plans (NCPs).
Nursing care plans are essential tools for documenting nursing diagnoses, interventions, and goals. Nurses must construct nursing care plans for efficient and standard communication between nurses, patients, and other healthcare providers. Care plans are particularly beneficial for nursing students as they gain experience in applying the nursing process.
Definition of what is a nursing care plan
A nursing care plan is a structured framework for providing patient care and is commonly referred to as the “ plan of care”. It describes the needs and risks of a patient. They guide nurses, the interprofessional team, and the patients, acting as a roadmap for patient care.
Components of a care plan
A typical nursing care plan (NCP) consists of nursing diagnoses, client issues, anticipated results, nursing interventions, and explanations for the interventions.
- Nursing diagnoses: describes the patient’s health problem or concern and is based on the information gathered from the assessment.
- Client health assessment: this is the information about the client, including age, emotional, sexual, or psychological.
- Anticipated results: These are the goals or targets planned to be achieved within a specified period.
- Nursing interventions: These are actions targeted to resolving the nursing diagnosis. The nursing interventions should be a clear path to the anticipated results.
- Rationales: These are scientifically supported justifications for the nursing actions prescribed.
- Evaluation: This involves monitoring and assessing a patient’s development and making appropriate adjustments to the treatment plan.
Different types of nursing care plans
Nursing care plans are either formal or informal. Informal nursing care plans are sets of instructions that a nurse mentally develops while formal nursing plans are documented guides that arrange the clients’s care details.
Formal nursing plans can be categorized into standardized and individualized care plans. Standardized plans outline nursing care for groups of clients with common needs while individualized plans are customed to address a specific client’s unique and unmet needs.
Standardized care plans are pre-developed guidelines created by nursing staff and healthcare organizations to guarantee consistent care for patients with specific conditions. They ensure certain standards are met. They also save time by reducing the repetitiveness of developing nursing care plans for individual patients who require common activities.
Individual care plans involve a custom approach to clients with unique needs. Patient satisfaction is great with individual care plans because the tailored approach makes the patients feel heard and valued.
What are the objectives of nursing care plans?
The objectives of nursing care plans include:
- Acts as a measurement for nursing care.
- Properly states the goals and the expected outcomes.
- Line of communication between nurses, patients, and other healthcare providers.
- Ensures nursing care is based on evidence and creates a comfortable and welcoming environment in hospitals or healthcare facilities.
- Promotes team effort and patient satisfaction.
Purposes
Some of the importance of writing a nursing care plan are:
- Continuity of care: A nursing care plan outlines the goals and the actions to carry out to achieve the goals. Nurses use the data in the nursing care plan to provide the same care to the patients.
- Defines the role of a nurse: nursing care plans outline the role of each individual in play, this helps the nurses identify their role in the nursing interventions.
- Provides directions to the client: to achieve the goal. the nurse care plans contain the instructions for the patient to adhere to.
- Documentation: the nursing care plan also acts as the official record of the patient’s care, progress, and any changes in their condition.
- Monitor progress: nurses can use the documentation in the nursing care plans to track the patient’s progress. If need be, adjustments can be made.
- Guide for insurance or healthcare payment: the nursing care plan carefully outlines the services and activities carried out to achieve the patient’s goal. These can be used as medical records to track the payments.
Care plan formats
The typical layout for nursing care plans involves four columns: nursing diagnoses, desired outcomes and goals, nursing interventions, and evaluation. In some cases, a three-column format is used, combining goals and evaluation in one column. Alternatively, certain agencies utilize a five-column plan that incorporates a column for assessment cues.
A comprehensive guide on how to write a nursing care plan
Developing an effective and efficient nursing care plan involves following these steps:
1. Data collection or assessment
The first thing to do when formulating nursing care is to establish a client database by utilizing assessment methods and data collection techniques. Through this database, all the health information about the patient is gathered. The data is then used to come up with a nursing diagnosis.
2. Data analysis and organization
After the information about the client is obtained, it is used in data analysis. The data is arranged collectively and is used to formulate the nursing diagnosis and goals.
3. Formulating the nursing diagnoses
Identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems are all part of nursing diagnoses, which provide a uniform way of addressing these issues.
4. Priority setting
After formulating the diagnosis, the nurse and the patient decide which identified problems require immediate attention. These problems are then categorized as high, medium, or low priority, with life-threatening issues receiving the highest priority. Maslow’s hierarchy of Needs assists in prioritizing and organizing care according to patient-centered goals.
5. Formulating the desired goals
For each priority, a goal is set. The objectives represent the intended results that both the patient and nurse hope to accomplish following the implementation of nursing interventions based on the client’s nursing diagnoses. The goals serve as checkpoints for tracking the patient’s progress.
6. Selection of nursing interventions
Nursing interventions are the tasks or measures carried out by a nurse to accomplish client objectives. The selected interventions should aim to eliminate or decrease the cause of the primary nursing issue or diagnosis. In the case of risk nursing issues, interventions should aim to minimize the client’s risk factors.
7. Rationale provision
Rationales are scientific explanations explaining why the measures were carried out. The text below should be remembered. The inclusion of these elements is intended to help nursing students link pathophysiological and psychological principles with the chosen nursing interventional principles.
8. Evaluation
Evaluation is a deliberate, continuous, and meaningful process in which the client’s advancements toward reaching objectives or desired results are evaluated, and the efficiency of the nursing care plan (NCP) is assessed.
9. Documenting it on paper
The nursing care plan is documented and becomes part of the client’s permanent medical record.
List of nursing care plans
Here is a list of sample nursing care plans (NCPs) for various diseases:
- Acute confusion and Altered Mental Status
- Cancer (Oncology Nursing)
- Hyperthermia (Fever)
- Grieving and Loss
- Prolonged Bed Rest
- Total Parenteral Nutrition
- Hysterectomy
- Mastectomy
- Thyroidectomy
- Heart Failure
- Hypertension
- Metabolic Acidosis
Sample nursing care plan
Here is a nursing care plan sample:
The nurse evaluates the client who was in a motor vehicle accident. The client reports a pain level of 8/10 in their right elbow. Through an x-ray, the client is determined to have a dislocated elbow, and the nursing diagnosis of acute pain is applied. The nurse begins planning treatment and goals to reduce pain and instill comfort. The nurse administers V pain medication as ordered and supports the right arm with pillows. The nurse evaluates the effectiveness of interventions by asking the client to rate their pain on a scale of 0-10. Depending on the outcome, the nurse may determine that the intervention was successful or requires revision.
FAQS for Nursing care plans
Does a nursing care plan work? Yes, a nursing care plan works.
How often do nurses update a care plan? Nurses should update their care plan every time there are significant changes in the patient’s health.
How do I write a nursing care plan? To write a nursing plan, assess the patient, make a diagnosis, set the outcomes, determine the nursing interventions, and evaluate the plan.
In conclusion, understanding and effectively utilizing nursing care plans (NCPs) is crucial for delivering high-quality patient care. They serve as great documentation tools and store the patient’s medical history. Writing clear and high-quality nursing care plans is an undeniable skill that nurses must learn to ensure patients are well cared for.
