Nursing Care Plans
What is a nursing care plan?
A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost.
Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice Nursing Care Plans.
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Types of Nursing Care Plans
Care plans can be informal or formal: An informal nursing care plan is a strategy of action that exists in the nurse‘s mind. A formal nursing care plan is a written or computerized guide that organizes the client’s care information. Formal care plans are further subdivided into standardized care plans and individualized care plans: Standardized care plans specify the nursing care for groups of clients with everyday needs. Individualized care plans are tailored to meet the unique needs of a specific client or needs that are not addressed by the standardized care plan.
Objectives
The following are the goals and objectives of writing a nursing care plan:
- Promote evidence-based nursing care and to render pleasant and familiar conditions in hospitals or health centers.
- Support holistic care which involves the whole person including physical, psychological, social and spiritual in relation to management and prevention of the disease.
- Establish programs such as care pathways and care bundles. Care pathways involve a team effort in order to come to a consensus with regards to standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease. Nursing Care Plans
- Identify and distinguish goals and expected outcome.
- Review communication and documentation of the care plan.
- Measure nursing care.
Purposes of a Nursing Care Plan
The following are the purposes and importance of writing a nursing care plan:
- Defines nurse’s role. It helps to identify the unique role of nurses in attending the overall health and well-being of clients without having to rely entirely on a physician’s orders or interventions.
- Provides direction for individualized care of the client. It allows the nurse to think critically about each client and to develop interventions that are directly tailored to the individual.
- Continuity of care. Nurses from different shifts or different floors can use the data to render the same quality and type of interventions to care for clients, therefore allowing clients to receive the most benefit from treatment.
- Documentation. It should accurately outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. If nursing care is not documented correctly in the care plan, there is no evidence the care was provided.
- Serves as guide for assigning a specific staff to a specific client. There are instances when client’s care needs to be assigned to a staff with particular and precise skills.
- Serves as guide for reimbursement. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client.
- Defines client’s goals. It does not only benefit nurses but also the clients by involving them in their own treatment and care. Nursing Care Plans
Components
A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales. These components are elaborated below:
- Client health assessment, medical results, and diagnostic reports. This is the first measure in order to be able to design a care plan. In particular, client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic and environmental. Information in this area can be subjective and objective.
- Expected client outcomes are outlined. These may be long and short term.
- Nursing interventions are documented in the care plan.
- Rationale for interventions in order to be evidence-based care.
- Evaluation. This documents the outcome of nursing interventions Nursing Care Plans.
Also check: Assignment: Practicum Client Termination Summary