How To Create A Nursing Care Plan

What is the definition of a nursing care plan?

A nursing care plan (NCP) is a structured process for assessing current needs and anticipating future needs or risks. Care plans facilitate communication between nurses, their patients, and other healthcare providers, resulting in improved health outcomes. Without the nursing care planning process, the quality and consistency of patient care would suffer.

Nursing care planning begins upon admission to the agency and is updated on a regular basis in response to changes in the client’s condition and assessment of goal achievement. The planning and delivery of individualized or patient-centered care is the bedrock of nursing excellence.

Nursing Care Plan Types

There are both informal and formal care plans available: An informal nursing care plan is a mental strategy for nursing care that exists solely in the nurse’s mind. A written or computerized manual that organizes the client’s medical information is referred to as a formal nursing care plan. The term “formal care plans” refers to both standardized and individualized care plans. For groups of clients with similar needs, nursing care is specified in standardized care plans. Individualized care plans are created to address the unique needs of a particular client or to address gaps in the standardized care plan.

Objectives

The following are the goals and objectives of writing a nursing care plan:

Promote evidence-based nursing care and create pleasant and familiar hospital or health center environments.
Sustain a holistic approach to patient care that considers the entire person, including physical, psychological, social, and spiritual facets, when it comes to disease prevention and management.
Create programs such as care pathways and bundles of care. Care pathways necessitate collaboration to agree on standards of care and expected outcomes, whereas care bundles are linked to best practices in terms of care provided for a particular disease.
Distinguish between objectives and anticipated outcomes.
Examine the communication and documentation associated with the care plan.
Nursing care should be quantifiable.

The Nursing Care Plan’s Purposes

The following objectives and significance of developing a nursing care plan are as follows:

Defines the role of the nurse. It enables nurses to recognize their unique role in addressing clients’ overall health and well-being without relying solely on physician orders or interventions.

Provides direction for the client’s unique care. It enables the nurse to think critically about each client and design interventions that are unique to each.

Continuity of care. Nurse practitioners working on different shifts or floors can use the data to ensure that clients receive the same level of care and type of intervention, maximizing their benefit from treatment.

Documentation. It should specify which observations should be made, which nursing actions should be performed, and which directions the client or family members require. If nursing care is not properly documented in the care plan, there is no evidence that it was provided.

Serve as a point of reference when it comes to assigning specific personnel to specific clients. At times, it is necessary to assign a client’s care to a staff member who possesses specific and precise skills.

It serves as a guide for reimbursement. The insurance industry uses the client’s health history to determine how much they will pay for hospital care.

Establishes the client’s goals. By involving clients in their own treatment and care, it benefits both nurses and clients.

Components

A nursing care plan’s components include nursing diagnoses, client problems, anticipated outcomes, and nursing interventions and rationales (NCP). The following elements are discussed in greater detail:

Health assessment, medical results, and diagnostic reports This is the initial step toward creating a care plan. Clients are evaluated based on their physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental characteristics. This data can be subjective or objective.
The client outcomes that are anticipated are detailed. These can be long- or short-term in nature.
Nursing interventions are documented in the care plan.
Evidence-based care requires interventions to have a rationale.
Assessment. This is a document that documents the outcomes of care processes.

How to Write a Nursing Care Plan

What is the proper format for a nursing care plan (NCP)? Create a care plan for your patient by following the steps outlined below.

Step 1: Collecting or Evaluating Data

The first step in developing a nursing care plan is creating a client database through assessment and data collection techniques (physical assessment, health history, interview, medical records review, diagnostic studies). All health data collected is stored in a client database. The nurse can use this step to identify associated or risk factors, as well as distinguishing characteristics, that will be used to formulate a nursing diagnosis. Utilize the evaluation formats provided by certain departments or nursing platforms.

Step 2: Analyze and Organize the Data

After obtaining data regarding the client’s well-being, analyze, cluster, and organize the data in order to develop your nursing diagnosis, preferences, and desired outcomes.

Step 3: Developing Nursing Diagnoses

NANDA nursing diagnoses are a standardized method for identifying, focusing on, and responding to the needs and reactions of specific clients to actual and high-risk concerns. Nursing diagnoses are actual or potential health problems that can be avoided or resolved through objective nursing intervention.

Step 4: Prioritization

Prioritization is the process of determining the preferred order in which to address nursing diagnoses and interventions. The nurse and the client collaborate to determine which nursing diagnosis should be addressed first. Diagnoses can be prioritized and classified as severe, moderate, or mild. Priority should be given to life-threatening situations.

A nursing diagnosis takes Maslow’s Hierarchy of Needs into account and assists in prioritizing and planning patient-centered care. In 1943, Abraham Maslow developed a hierarchy based on the innate needs of all individuals. Prior to achieving higher needs/goals such as self-esteem and self-actualization, basic physiological needs/goals must be met. Nursing care and nursing interventions are based on physiological and safety requirements.

Maslow’s Hierarchy of Needs

The basic physiological needs are nutrition (water and food), elimination (toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep, sex, shelter, and exercise.

Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, and seat belts), establishment of a trusting and safe environment (therapeutic relationship), and patient education (modifiable risk factors for stroke, heart disease).

Developing supportive relationships, avoiding social isolation (bullying), employing active listening techniques, therapeutic communication, and sexual intimacy are all ways to experience feelings of love and belonging.

Acceptance in the community, at work, personal achievement, a sense of control or empowerment, and acceptance of one’s physical appearance or body habitus are all indicators of self-esteem.

Self-Actualization is defined as the process of creating an empowering environment, spiritual development, the capacity to understand the perspectives of others, and realizing one’s full potential.

Prioritization requires the nurse to consider the client’s health values and beliefs, as well as his or her own preferences, available resources, and urgency. Involve the client in the method to foster cooperation.

Step 5: Determining the Client’s Objectives and Desired Outcomes

After assigning priorities to your nursing diagnosis, the nurse and client establish goals for each determined priority. The nurse’s goals or intended outcomes define what she hopes to accomplish by incorporating nursing interventions based on the client’s nursing diagnoses. Goals direct intervention planning, serve as criteria for assessing client progress, enable the client and nurse to determine which problems have been resolved, and serve to motivate both parties through a sense of accomplishment.

Each nursing diagnosis is guided by a single overarching objective. The terms “objective,” “outcome,” and “expected outcome” are frequently used interchangeably. SMART objectives should be established. SMART goals are defined as Specific, Measurable, Attainable, Realistic, and Time-Bound objectives.

Specific.

A goal must be clear, significant, and reasonable in order to be effective.
Measurable or significant.
By ensuring that a goal is measurable, it becomes easier to track progress and determine when it has been accomplished.
Possibilistic or action-oriented.
Goals should be adaptable but still achievable.
Affirmative or result-oriented.
This is critical in order to anticipate effective and successful outcomes while considering the available resources.
Timely or time-sensitive.
Each objective requires a time frame and a deadline to focus on and something to work toward.
Goals for the Short and Long Term

The objectives and anticipated outcomes must be quantifiable and centered on the client. Goals are established by focusing on the prevention, resolution, and rehabilitation of problems. Objectives can be either short- or long-term in nature. The majority of goals in an acute care setting are short-term, as the nurse’s time is consumed by the client’s immediate needs. Long-term goals are frequently used with clients who have chronic health problems or live in nursing homes, assisted living facilities, or long-term care facilities.

Short-term goal – a statement indicating an immediate change in behavior, typically within a few hours or days.
Long-term goal – refers to an objective that will be accomplished over a longer period of time, typically weeks or months.
Discharge planning – identifies long-term objectives, thereby promoting continued restorative care and problem resolution through home health, physical therapy, or a variety of other referral sources.
Step 6: Nursing Interventions Selection

Nursing interventions are activities or actions undertaken by a nurse to assist a client in achieving their objectives. The interventions should be chosen with the objective of eradicating or significantly reducing the etiology of the nursing diagnosis. Risk nursing diagnoses should be treated with interventions aimed at reducing the client’s risk factors. While nursing interventions are identified and documented during the planning stage of the nursing process, they are actually implemented during the implementation stage.

Nursing Interventions of Various Types

Independent nursing interventions are activities that nurses may initiate based on their sound judgment and abilities. The job requires continuous assessment, emotional support, comfort, teaching, physical care, and referrals to other health care professionals.

Nursing interventions that are dependent on a physician are those that are carried out on his or her orders or under the supervision of a physician. All orders to the nurse are included, including those for medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest. Additionally, while administering medical orders, dependent nursing interventions include assessment and explanation.
Nurses collaborate on interventions with other members of the health care team, such as physicians, social workers, dietitians, and therapists. These actions are developed in collaboration with other health care professionals to gain their perspective.

Writing nursing interventions: Some pointers
Date and sign the plan. Date of creation is critical for evaluation, review, and future planning. The signature of the nurse establishes accountability.
Nursing interventions should be precise and unambiguous, beginning with an action verb indicating the nurse’s expected behavior. The intervention must begin with an action verb that is precise. The how, when, where, time, frequency, and amount of the planned activity define its content. For instance, “Educate parents on proper temperature taking technique and notification of any changes,” or “Assess urine for color, quantity, odor, and turbidity.”
Utilize only abbreviations that the institution recognizes.
Step 7: Justification

Rationales, alternatively referred to as scientific explanations, explain why the nursing intervention for the NCP was chosen.

Regular care plans do not include rationales. They are included to assist nursing students in associating the selected nursing intervention with pathophysiological and psychological principles.

Step 8: Evaluation

Evaluating is a deliberate, ongoing, and intentional activity that assesses both the client’s progress toward achieving goals or desired outcomes and the nursing care plan’s effectiveness (NCP). Because the conclusions reached during this step dictate whether the nursing intervention should be discontinued, continued, or modified, evaluation is a critical component of the nursing process.

Step 9: Compose it

According to hospital policy, the client’s NCP is documented and becomes part of the client’s permanent medical record, which the oncoming nurse may review. Care plan formats vary according to nursing programs. Most are organized in a five-column format to guide the student through the interconnected steps of the nursing process.

Plans for Basic Nursing and General Care

Examples of non-standard nursing care plans:

End-of-Life Care for Patients with Cancer (Oncology Nursing) (Hospice Care or Palliative)
Nursing Care for the Elderly (Older Adult)
Surgical procedure (Perioperative Client)
Lupus Erythematosus Systemic
Nursing Care Plan for Total Parenteral Nutrition Assistance

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