A nursing care plan highlights the current and potential needs of a patient. It is an important process in ensuring the quality of patient care is top notch and is a form of communication between healthcare providers and patients. A nursing care plan commences the moment a patient is admitted and is changed at intervals depending on the patient’s changes, response and condition. In this article, we are going to take you through a nursing care plan, and how to write it.
Types Of Nursing Care Plans
A care plan can either be formal or informal. Formal nursing care plan is usually in written form while an informal care nursing plan is usually in a nurse’s mind. Formal nursing care plan is the divided into standardized and individualized nursing care plans.
Standardized nursing care plan
These are unexecuted plans by nurses to ensure patients certain problems receive unlimited care. This plan ensures the legal criteria is used for a systematic use of nurses’ timeline by eliminating repeated activities in a facility.
Individualized nursing care plan
This is a series of standardized care plans set to accomplish the needs and goals of an individual patient. This plan promotes personalized care to a patient’s needs and helps nurses to develop treatment plans for individual patients. Individualized nursing care plan builds the relationship between nurses and patients because patients get satisfied knowing that their needs are cared for at a personal level.
Importance of a nursing care plan
The purposes of a nursing care plan are as follows:
- It assists in keeping track of a patient’s progress and response so as to determine whether there will be changes in the plan
- It is a guide to determine which nurse will attend to the patient since some conditions require nurses skilled in that field
- It promotes good coordination of healthcare workers considering that they are aware of the patient’s needs and the actions needed to prevent breaking of the nursing process cycle.
- It ensures that different nurses looking after the patient deliver quality interventions while caring for them
- It helps in identifying a nurse’s unique role and specialty in serving their patients without depending on a physician.
- It serves as a direction for nurse to the care they should provide to patients and may require them to think critically to determine the intervention they will apply to patients.
Components of nursing care plan
A nursing care plan consists of the following:
- The patient’s analysis, results and reports which can be objective or subjective
- A diagnosis to elaborate the patient’s condition
- The expected results either long or short term
- Interventions to be carried out during the diagnosis to meet the goals
- Explanations of the interventions used accompanied by evidence
- Plans developed to monitor the patient’s progress and making changes where necessary depending on their response
How to write a nursing care plan
The steps to follow when writing a nursing care plan are as follows:
- Collecting data: Create a directory for the patient by assessing and collecting data by inquiring about their health history, interviewing them, reviewing medical records and assessing them physically. The directory should include all possible health data you can collect and some facilities have a specific way of doing so.
- Analyzing data: After collecting the data, you can proceed to grouping it so you can come up with treatment plans, nursing diagnosis and expected results.
- Prepare a diagnosis: This is a common way of dealing with patient’s needs and problems individually and identifying their responses so you can identify the appropriate interventions.
- Set preferences: During this stage, the nurse and patient come to terms to determine which problem should be sorted first. They can be grouped as either high priority, low priority or medium priority and problems that pose risks to the patient are classified as high priority.
- Create goals and the expected results: Goals are the expectations a nurse and patient have after interventions depending on the patient’s diagnoses. Goals should be specific, attainable, measurable, timely or realistic. Goals can be categorized as either long-term or short-term.
- Decide on the appropriate interventions: These are activities that are aimed at achieving the det goal and they mostly target to do away with the cause of the problem. The interventions should be recorded as proof of implementation during the nursing process. The types of interventions are: collaborative intervention, independent interventions and dependent interventions.
- Provide explanations: You provide reasons you chose certain interventions in the care plan. However, they are not included in a normal care plan because they are set to help student familiarize with principles of the selected intervention.
- Sum up: summing up is done through evaluation where a patient’s progress is examined and assess the efficiency of the care plan. The evaluation stage is very essential in determining whether the care plan should be changed, done away with or continued.
- Document everything: Your findings should be recorded and filed in the patient’s medical record for easy review by incoming nurses.
Conclusion
The goal of a nursing care plan is to provide clarity on the type of interventions to be used on a certain patient. While writing a care plan, you should be very careful and fill out the sections provided correctly. A nursing care plan should enable nurses locate a patient’s records easily in one file., and it should be updated regularly. We hope this article has provided important details on a nursing care plan and how you can write one,
FAQs
1. What are the stages of a nursing care plan?
The stages are: examination, planning, implementation and following up
2. What are the available types of care plans?
Care plans include: treatment plan, nursing plan, action plan and discharge plan
3. Who is responsible for writing a care plan?
Medical professionals write the care plan with a little help from the patient on how they would like to be cared for.
4. What is a care plan?
A care plan refers to a record that states a patient’s need, services to be offered, the service provider and duration of service provision.