Nursing care plan is a process that is used to determine the needs of a patient.
A nursing care plan is like a blueprint for providing patient care or a plan of action for providing patient care. Nursing care plans can be individualized for each patient or standardized for a group of patients. Individualized care plan meets the demands of each client or patient in every possible way, one care plan may not work for multiple patients so individualized care plans are made as a patient-centered service plan so the patient may receive a holistic care. On the other hand, a standardized care plan helps the nurse to be more efficient in the nursing data management field; however, the patient’s health outcome remains uncertain.
Nursing care plans are of two types – one is formal and the other one is informal.
Informal care plans are the strategic plan of action a nurse is about to take when a client/patient has been assessed and all the plans are in the mind, not in any form of document or electronic file. Informal care plans are risky to some sort because if the nurse is not experienced in the area of the patient’s need, then the overall outcome of the patient remains uncertain. Formal care plans are documented version that is either written or computerized. A formal care plan contains the proper direction for how a nurse should diagnose the patient and what kind of care the patient need.
Furthermore, formal care plans can be subdivided into two categories, one is written and the other one is computerized. Since the beginning, the written method has been trustworthy but in this era of modernization, technology has taken its leap even in the medical sector, computerized care plans are the digital way of writing care plans. Using a computer or any device when creating nursing care plans is more accurate, accessible, it can be easily edited and updated and formatted in comparison to handwritten care plans.
A proper care plan contains all the necessary information of the care planning (care planning allows a nurse to identify a patient’s problems and select interventions that’ll help solve or minimize problems), care plans are the written record of care planning. From workplace to workplace, nursing care plans vary. But in most cases, the pattern is the same. In general, it can be expected that all kinds of pertinent information: the diagnoses, the anticipated outcome, nursing orders, and evaluation will be of same. A care plan is created based on both theory and practice.
Care plans are used to facilitate evidence based holistic care, it means that when a patient is assessed and admitted, he/she is counted as a whole and not just for certain symptoms or diseases so, therefore, is permitted to receive an overall care as holistic nursing care believes that mind and body are inseparable and should be treated as a whole.
Purpose of a Care Plan
Nursing care plans allow the nurses and staff to acknowledge the care that they are providing. A nursing care plan is a thinking planning process; it helps build up a nurse with experience and knowledge by performing various practical tasks. When a care plan is provided to a nurse or when they create a care plan, a nurse is then responsible for the whole process of the patient’s care until the plan passes onto another nurse and thus it allows the nurse to clear their thinking and solely focus on the patient care.
The nursing care plan is a means of communicating and the constant changing of the shifts of nurses. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds thus providing a continuity of care. A care plan helps build up the communication of the nurses with all the healthcare providers and among them as well.
Care plans serve as an advisor for the allocation of staff to care for the patient. There may be certain particular of the patient’s care that needs to be assigned to healthcare providers with specific skills. Care plans help teach documentation and recording. The care plan specifically indicates which observations to make, what actions to carry out and what instructions the patients and their family members should receive.
Care plans teach nurses and students how to think analytically about all the critical factors and how to view the patient as a whole not just as a patient with the disease, this helps to care for the patient on a more personal level. It also helps the nurses to learn more about priority and intervention. Care plans guide the nurses and students to stay true to the care and not cause trifles over the care.
Components of Care Plan
A care plan contains the following components:
2. Nursing Diagnosis
Components of the care plan give specific direction as to how the care should proceed or in what path the care is more efficient.
The first component is the assessment process, before a patient is admitted, the healthcare providers perform a full body assessment to gather data, for example, vital signs or any abnormal patient behavior or to figure out of what disease the patient is suffering. Client/patient assessment is the first step in creating careful planning.
The second component is the nursing diagnosis. The nurse collects the information from the assessment, analyzes the information and identifies problems where patient outcomes can be improved through the use of nursing interventions.
Nursing diagnoses are different from medical diagnoses because while medical diagnoses focus on the disease, nursing diagnoses are more patient-centered.
The third component is the planning phase. The nurse creates a path for diagnoses and which diagnosis needs to be focused on. The patient can be involved in this process as well. The main focus of this process is to create an overview of the whole care plan.
The fourth component is the implementation process. When implementing nursing orders, the patient gets continuously assessed by the nurses, the nurses collect data continuously according to the patient’s response. Implementing care plans successfully, a tactical nurse with good interpersonal and technical skills as well as intellectual skills.
And last but not least is the evaluation process, it’s the judgment of the effectiveness of the nursing care to meet patient goals based on the patient’s overall behavior process. The last phase is to determine whether the goal has been met or not, if the goals are not met, care plans are revised and if the goals are met, more effectiveness is implemented.
By creating and implementing individualized nursing care plans, healthcare professionals can ensure that patients receive the best possible care. The nursing process, including assessment, diagnosis, planning, implementation, and evaluation, forms the backbone of effective nursing care plans.
It is crucial to regularly review and update the nursing care plan to ensure that it reflects the patient’s current needs and goals. Ultimately, nursing care plans promote patient-centered care and help healthcare professionals provide safe and effective care to their patients.