Nursing care plan

A nursing care plan is a method by which medical personnel, mainly nurses, compile and share important information about patients and their treatment. Care plans record data such as a patient’s detailed diagnosis, actions taken by or required of nurses, and evaluations of the patient’s progress toward health goals. Nursing care plans are essential in the complex world of modern healthcare as they allow multiple healthcare personnel to easily access and update the same patient information. This helps nurses and other medical personnel work as a team. It also creates important documentation of a patient’s health as well as treatments received, which can be added to health records or insurance reports.

Background

Modern healthcare can be complicated. In most medical facilities, numerous members of the medical staff may work with an individual patient. Each staff member brings a different set of qualifications, skills, experiences, and perspectives. Scheduling and assignment changes may add further variability to the interactions between medical staff and their patients.

Without efficient communication between medical personnel, each staff member would have to start fresh with each patient, assessing all treatments and requirements. This could lead to serious delays, confusion, and potentially insufficient data, possibly inhibiting a patient’s treatment.

For these reasons, careful recordkeeping and planning is essential in the healthcare environment. Nurses and other staff members involved with a patient should have access to the same vital information about that patient. They should also cooperate to carry out a shared vision of how to improve that patient’s health. One fundamental means of sharing this necessary information is through nursing care plans. These plans allow medical staff to work as unified teams with shared knowledge and goals.

Nursing care plans can take several forms. The most basic is the informal care plan, which exists in the mind of the nurse. The informal care plan may be simple guidelines used for patients who do not require any ongoing or extensive treatment. For example, this kind of plan may be used for a one-time visit for a sprained ankle. It also may serve as a preliminary step toward a more comprehensive plan.

As soon as a plan is written, whether on paper or recorded digitally, it is considered a formal nursing care plan. One such type of plan is the standardized care plan, which is a relatively general plan used for patients needing a certain category of care. If a patient needs specialized help, the standardized care plan is customized into a more detailed individualized care plan tailored to more specific patient needs. Individualized care plans may grow greatly over time and include contributions from many nurses.

Overview

In general, nursing care plans are processes by which nurses and other medical personnel record and share important facts about a patient. The data in these plans include the patient’s current condition, needs, and potential risks. The development of a nursing care plan begins as soon as a patient arrives for treatment, and may continue for hours, days, months, or even years, depending on the situation. The plans are constantly checked, revised, and updated to reflect the patient’s changing situation. Optimal nursing care plans ensure that the level of healthcare is efficient and effective.

One of the main objectives of nursing care plans is to help the patient receive the best care possible. This involves ensuring that each patient receives individual treatment and can feel comfortable with caretakers, assured that their needs are known and understood. Care plans also help experts work with individual patients in a variety of ways, creating holistic care programs that can help patients prosper physically, mentally, and emotionally.

Nursing care plans are also helpful for healthcare institutions. These plans can help teams of medical personnel analyze cases and reach agreements on how to proceed with care. Nursing plans can also help caregivers create long-term goals and measure and evaluate the types and level of care received during treatment. The latter information is important both for the updating and accuracy of health records and for reporting to insurance companies.

Though medical needs and care can vary greatly, most nursing care plans follow a similar basic format. In general, these plans address crucial topics such as the patient’s diagnosis, the anticipated outcome of the treatment, actions taken or required of nurses, and evaluations of the patient’s current state.

The patient’s diagnosis is a fundamental piece of information for a nursing care plan as it helps to inform and guide the rest of the planning. Medical personnel will need to understand the patient’s specific situation before taking any serious course of treatment. To ensure the most accurate diagnosis, nurses may have to thoroughly assess a patient. This includes analysis of their physical and mental status. Frequently, a full diagnosis must also take into account less-tangible factors such as the patient’s social, economic, cultural, and spiritual background. These factors may not seem immediately pressing, but may prove very important to successful treatment.

Assessing the anticipated outcome of the treatment in a nursing care plan is an important method of guiding nurses’ choices and actions. In these plans, nurses start with a health goal and then create a map of actions most likely to lead to that goal. These actions, often referred to in planning as nursing orders or interventions, list the steps nurses should take to best care for the patient. This information may contain a high level of specificity—such as an amount of medicine to be administered at a certain time—as well as broad longer-term goals. These action plans may be revised over time according to the patient’s progress.

The final main section of a nursing care plan is the evaluation, which records the actions taken and the results in regards to the patient. This evaluation helps nurses determine whether treatments are working or require alteration. It also helps nurses and other personnel decide when a patient has reached a goal and may be considered healthy enough to be discharged from care.

Bibliography

Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Nursing Diagnosis and Intervention. 9th ed. Mosby, 2016.

Papandrea, Dawn. “Nursing Care Plans: What You Need to Know.” Nurse.org, 8 Jan. 2018, nurse.org/articles/what-are-nursing-care-plans/. Accessed 5 June 2019.

Schultz, Judith M., and Sheila L. Videbeck. Lippincott’s Manual of Psychiatric Nursing Care Plans. 9th ed. Wolters Kluwer/Lippincott, Williams, & Wilkins, 2012.

“The Nursing Process.” American Nurses Association, www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/. Accessed 5 June 2019.

“The Ultimate Nursing Care Plan Database.” NRSNG, 2019, www.nrsng.com/nursing-care-plans/. Accessed 5 June 2019.

Vera, Matt. “Nursing Care Plans (NCP): Ultimate Guide and Database.” Nurseslabs, 31 Jan. 2019, nurseslabs.com/nursing-care-plans/. Accessed 5 June 2019.

“What Is a Nursing Care Plan and Why is it Needed?” RN Central, 2019, www.rncentral.com/nursing-library/careplans/. Accessed 5 June 2019.

Yazdi, Mariam. “4 Steps to Writing A Nursing Care Plan.” Nurse.org, 23 Mar. 2018, nurse.org/articles/nursing-care-plan-how-to/. Accessed 5 June 2019.