Nursing Care Plans are a vital part of providing quality nursing care. A care plan is a personalized plan of action designed to meet the individual health needs of each patient. It outlines a nurse’s goals and interventions for promoting optimum health, preventing illness, and managing symptoms. By having a clear goal or direction for the patient’s treatment, nurses can provide coordinated, systematic care tailored to the individual’s needs.
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What are Care Plans for Nursing ?
A Nursing Care Plan is a written action plan outlining the nursing care to be provided to an individual patient. It is a tool nurses use to provide a comprehensive and organized approach to assessing, planning, implementing, and evaluating a patient’s healthcare needs. The plan typically includes the following:
- The diagnosis or problem list
- Interventions for addressing the problems/diagnoses
- Expected outcomes in addressing the issues/diagnoses
- Evaluation of progress toward meeting the desired goals
The plan is tailored to each individual, as each patient’s needs are unique.
What is the Purpose of a Nursing Care Plan
• To identify patient problems: The primary purpose of a nursing care plan is to carefully assess the patient and identify any existing or potential problems. Through this assessment, the nurse can create an organized list of diagnoses/problems that must be addressed. This initial step helps to ensure that all of the patient’s needs are taken into account when creating a plan of action.
• To set achievable goals: Once the problems/diagnoses have been identified, the nurse can create a plan of action to address each issue. This plan should include realistic and achievable goals tailored to the patient’s needs. The goals should be measurable to track progress and determine if further interventions are necessary.
• To develop interventions: The plan should include a variety of interventions to address the identified problems/diagnoses effectively. Interventions can include medications, therapies, lifestyle changes, etc. Depending on the patient’s needs, the nurse may need to work with other healthcare professionals to develop an appropriate intervention plan.
• To evaluate progress: The evaluation phase is one of the most important components of a nursing care plan. During this phase, the nurse will review the patient’s progress toward meeting the desired goals and determine if any modifications to the plan are necessary. Through regular evaluation and monitoring, the nurse can ensure that the chosen interventions are effective and that the patient’s needs are met.
• To provide a comprehensive approach: The nursing care plan provides a comprehensive approach to assessing, planning, implementing, and evaluating a patient’s healthcare needs. This holistic approach helps ensure that all of the patient’s needs are considered and addressed to achieve optimal health outcomes.
Benefits of Developing and Utilizing a Nursing Care Plan
• Improved patient care: The nursing care plan provides an organized approach to the assessment, planning, implementation, and evaluation of a patient’s healthcare needs. This comprehensive approach helps ensure that all of the patient’s needs are met to achieve optimal health outcomes.
• Increased collaboration: Developing and utilizing a nursing care plan can help facilitate greater collaboration between healthcare professionals. The plan can provide insight into the patient’s condition, which helps other healthcare professionals better understand and address the patient’s needs.
• Enhanced communication: Utilizing a nursing care plan can help ensure clear communication between all of the healthcare team members. The plan provides a common language to discuss issues related to a patient’s care.
• Improved documentation: Using a nursing care plan can help improve the accuracy and consistency of healthcare documentation. The plan provides an organized framework for recording patient information, which helps to ensure that all relevant information is accurately documented.
• Increased efficiency: Utilizing a nursing care plan helps streamline the assessment, planning, implementation, and evaluation phases of care. This leads to more efficient and effective patient care, as healthcare professionals can quickly identify a patient’s needs and develop an appropriate action plan.
Steps to Develop an Effective Nursing Care Plan
Step 1:
Assess the Patient’s Needs– The first step in developing a nursing care plan is to assess the patient’s needs. This involves obtaining a thorough health history and performing any necessary physical assessments. During this assessment, the nurse should note any existing problems or potential issues that need to be addressed.
Step 2:
Make a Diagnosis– The next step is to identify the patient’s diagnosis or list of problems. It can be done by analyzing the information gathered during the assessment process and determining which diagnoses/problems must be addressed.
Step 3:
Establish Goals and Outcomes– Once the patient’s needs have been identified, the next step is to establish goals and expected outcomes for addressing the issues. The goals should be specific, measurable, achievable, relevant, and time-based to ensure they are realistic.
Step 4:
Determine Nursing Interventions– The next step is determining the appropriate nursing interventions for addressing the identified problems/diagnoses. This may involve working with other healthcare professionals to develop an appropriate action plan.
Step 5:
Monitor and Evaluate Progress– The last step is to monitor and evaluate the patient’s progress toward meeting the desired goals. During this phase, tracking the patient’s progress and modifying the plan as needed is vital.
Sample Nursing Care Plan: How does a Nursing Care Plan Looks Like
Patient Information:
Name: John Doe
Age: 57
Gender: Male
Diagnosis/Problems: Diabetes, Hypertension, Hyperlipidemia
Nursing Diagnoses:
• Risk for Injury related to decreased sensory perception secondary to diabetic peripheral neuropathy
• Imbalanced Nutrition: Less than Body Requirements related to decreased oral intake secondary to feelings of depression
• Ineffective Coping related to the inability to manage chronic health conditions
Goals and Outcomes:
• Patient will demonstrate improved sensory perception without injury by the end of the shift.
• Patient will maintain adequate nutritional status as evidenced by lab values within normal range by discharge.
• Patient will demonstrate improved coping skills as evidenced by increased participation in self-care activities by discharge.
Nursing Interventions:
• Assess patient’s level of sensation every 4 hours using a 10-point scale.
• Provide health teaching regarding wound care and proper foot hygiene to prevent further injury.
• Encourage patient to consume foods high in nutritional value and follow dietary instructions.
• Monitor weight daily and document progress toward a goal.
• Provide emotional support and encourage positive coping strategies such as relaxation techniques, journaling, and distraction activities.
• Refer patient to a social worker for additional counseling services if needed.
Evaluation:
The patient will demonstrate improved sensory perception without injury, maintain adequate nutritional status as evidenced by lab values within normal range, and improve coping skills by increased participation in self-care activities by discharge.
Tips for Writing an Effective NCP
- Include any labs or tests that were performed in the plan.
- Plan should include measurable, achievable goals and outcomes.
- Identify the nursing interventions appropriate for each patient’s needs.
- Include an evaluation section at the end of the plan to assess progress towards goals and outcomes.
- Monitor patient’s progress regularly and modify the plan as needed.
- Collaborate with other healthcare team members to ensure that all of the patient’s needs are addressed appropriately.
- Utilize evidence-based practice guidelines when possible.
- Ask for input from the patient and/or family members when creating the plan.
- Communicate the plan to all of the healthcare team members.
- Document any patient condition changes that may lead to plan modifications.
Final Words
A nursing care plan is an essential component of providing quality patient care. It helps ensure the patient receives the most effective and safe interventions possible while meeting their needs. A nursing care plan includes organized information about the patient’s condition, health history, treatment goals, and expected outcomes to create a plan of action for care.
Mrs. Marie Brown has been a registered nurse for over 25 years. She began her nursing career at a Level I Trauma Center in downtown Chicago, Illinois. There she worked in the Emergency Department and on the Surgical Intensive Care Unit. After several years, she moved to the Midwest and continued her nursing career in a critical care setting. For the last 10 years of her nursing career, Mrs. Brown worked as a flight nurse with an air ambulance service. During this time, she cared for patients throughout the United States.