Writing A Nursing Care Plan-Over 100 Nursing Writers

Writing A Nursing Care Plan

What is a nursing care plan?

A nursing care plan (NCP) is a formal process for identifying existing needs and recognizing potential needs or risks. Care plans facilitate communication among nurses, their patients, and other healthcare providers in order to achieve positive health outcomes. Without the nursing care planning process, patient care would suffer in terms of quality and consistency.

Nursing care planning begins when the client is admitted to the agency and is updated on a regular basis in response to changes in the client’s condition and evaluation of goal achievement. The foundation of excellence in nursing practice is the planning and delivery of individualized or patient-centered care.

Types of Nursing Care Plans

Informal or formal care plans are available: An informal nursing care plan is a strategy of action that exists only in the mind of the nurse. A formal nursing care plan is a written or computerized manual that organizes the client’s medical information. Formal care plans are further divided into standardized and individualized care plans: Nursing care is specified in standardized care plans for groups of clients with common needs. Individualized care plans are created to meet the specific needs of a specific client or to address needs that are not addressed by the standardized care plan.

Objectives

The goals and objectives of writing a nursing care plan are as follows:

  1. Promote evidence-based nursing care and make hospital or health center environments pleasant and familiar.
  2. Support holistic patient care, which involves the entire person, including physical, psychological, social, and spiritual aspects, in disease prevention and management.
  3. Create programs like care pathways and care bundles. Care pathways require a collaborative effort to reach an agreement on standards of care and expected outcomes, whereas care bundles are related to best practice in terms of care given for a specific disease.
  4. Identify and differentiate between goals and expected outcomes.
  5. Examine the care plan’s communication and documentation.
  6. Nursing care should be measured.

Purposes of a Nursing Care Plan

The following are the goals and significance of creating a nursing care plan:

Defines the nurse’s role. It aids in identifying nurses’ unique role in attending to clients’ overall health and well-being without relying solely on physician orders or interventions.

Provides guidance for the client’s individualized care. It enables the nurse to think critically about each client and create interventions that are specifically tailored to the individual.

Care continuity. Nurse practitioners from different shifts or floors can use the data to provide the same quality and type of interventions to clients, allowing them to benefit the most from treatment.

Documentation. It should clearly state which observations should be made, what nursing actions should be taken, and what directions the client or family members require. There is no evidence that nursing care was provided if it is not properly documented in the care plan.

Act as a reference for assigning specific personnel to individual clients. There are times when a client’s care must be assigned to a staff member who possesses specific and precise skills.

It is used as a reimbursement guide. The health history is used by insurance industry to evaluate how much they will pay for the client’s hospital care.

Defines the client’s objectives. It benefits both nurses and clients by involving them in their own treatment and care.

Components

Nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales are all common components of a nursing care plan (NCP). These elements are described in greater detail below:

  1. Assessment of the client’s health, medical results, and diagnostic reports This is the first step in developing a care plan. Client evaluation is focused on the following areas and abilities in particular: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. This information can be both subjective and objective.
  2. The anticipated client outcomes are outlined. These can be both long-term and short-term.
  3. The care plan includes documentation of nursing interventions.
  4. Interventions must have a rationale in order to be evidence-based care.
  5. Assessment. This is a record of the outcomes of care processes.

Writing a Nursing Care Plan

How should a nursing care plan (NCP) be written? Follow the steps outlined below to create a care plan for your patient.

Step 1: Data Gathering or Evaluation

First step in writing a nursing care plan is to generate a client database using assessment and data collection techniques (physical assessment, health history, interview, medical records review, diagnostic studies). All of the health information gathered is stored in a client database. In this step, the nurse can identify the related or risk factors as well as the distinguishing features that will be used to formulate a nursing diagnosis. You can use the evaluation formats provided by some departments or nursing platforms.

Step 2: Data Analysis and Organization

Now that you’ve obtained data about the client’s wellbeing, analyze, cluster, and organize the data to develop your nursing diagnosis, preferences, and desired outcomes.

Step 3: Formulating Your Nursing Diagnoses

NANDA nursing diagnoses are a standardized means of determining, focusing on, and responding to specific clients ’ needs and reactions to actual and high-risk concerns. Nursing diagnoses are actual and potential health problems that could be prevented or addressed by unbiased nursing intervention.

Step 4: Establishing Priorities

Setting priorities is the process of determining a preferred sequence for dealing with nursing diagnoses and interventions. In this step, the nurse and the client decide which nursing diagnosis needs to be addressed first. Diagnoses can be prioritized and categorized as high, medium, or low. Life-threatening issues should be prioritized.

A nursing diagnosis incorporates Maslow’s Hierarchy of Needs and aids in the prioritization and planning of patient-centered care. Abraham Maslow developed a hierarchy based on basic fundamental needs that are innate in all individuals in 1943. Basic physiological needs/goals must be met before higher needs/goals such as self-esteem and self-actualization can be attained. The implementation of nursing care and nursing interventions is based on physiological and safety needs.

Maslow’s Needs Hierarchy

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

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

Fostering supportive relationships, avoiding social isolation (bullying), using active listening techniques, therapeutic communication, and sexual intimacy are all ways to feel loved and belong.

Acceptance in the community, workplace, personal achievement, sense of control or empowerment, acceptance of one’s physical appearance or body habitus are all examples of self-esteem.

Self-Actualization: Creating an empowering environment, spiritual development, the ability to identify the perspectives of others, and achieving one’s full potential.

When assigning priorities, the nurse must recognize the client’s health values and beliefs, as well as the client’s own preferences, available resources, and urgency. In order to improve cooperation, involve the client in the method.

Step 5: Establishing Client Goals and Desired Outcomes

The nurse and the client set goals for each determined priority after assigning priorities for your nursing diagnosis. Goals or intended results define what the nurse hopes to accomplish by incorporating nursing interventions based on the nursing diagnoses of the client. Goals provide direction for intervention planning, serve as criteria for assessing client progress, allow the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of accomplishment.

Each nursing diagnosis has a single overarching goal. Goal, outcome, and expected outcome are terms that are frequently used interchangeably. SMART goals should be set. The acronym SMART stands for Specific, Measurable, Attainable, Realistic, and Time-Bound goals.

  • Specific. It should be clear, significant and sensible in order for a goal to be effective.
  • Measurable or Meaningful. Making sure a goal is measurable makes it easier to monitor progress and know when it reached the finish line.
  • Attainable or Action-Oriented. Goals should be flexible but still remains possible.
  • Realistic or Results-Oriented. This is important to look forward to effective and successful outcomes by keeping in mind the available resources in hand.
  • Timely or Time-Oriented. Every goal needs a designated time parameter and deadline to focus on and something to work toward.

Short Term and Long Term Goals

The objectives and expected outcomes must be measurable and client-centered. Goals are built by concentrating on problem prevention, resolution, and rehabilitation. Goals can be short-term or long-term in nature. In an acute care setting, most goals are short-term because the nurse’s time is spent on the client’s immediate needs. Long-term goals are frequently used with clients who have chronic health problems or who live at home, in nursing homes, or in long-term care centers.

  • Short-term goal – a statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days.
  • Long-term goal – indicates an objective to be completed over a longer period, usually over weeks or months.
  • Discharge planning – involves naming long-term goals, therefore promoting continued restorative care and problem resolution through home health, physical therapy, or various other referral sources.

Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse takes to help a client achieve their goals. Interventions should be chosen with the goal of eliminating or reducing the etiology of the nursing diagnosis in mind. Interventions for risk nursing diagnoses should focus on lowering the client’s risk factors. Nursing interventions are identified and written during the planning phase of the nursing process, but they are actually carried out during the implementation level.

Types of Nursing Interventions

Independent nursing interventions are activities that nurses are authorized to begin based on their sound judgment and skills. Continuous assessment, emotional support, comfort, teaching, physical care, and referrals to other health care professionals are all part of the job.

Dependent nursing interventions are activities performed on the orders or supervision of a physician. Orders to the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest are all included. The dependent nursing interventions also include assessment and explanation while administering medical orders.
Collaborative interventions are actions performed by nurses in collaboration with other members of the health care team, such as physicians, social workers, dietitians, and therapists. These actions are created in collaboration with other health care professionals in order to gain their professional perspective.

Tips to writing nursing interventions

  1. Write the date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning. The nurse’s signature demonstrates accountability.
  2. Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise. Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “Educate parents on how to take temperature and notify of any changes,” or “Assess urine for color, amount, odor, and turbidity.”
  3. Use only abbreviations accepted by the institution.

Step 7: Providing Rationale

Rationales, also known as scientific explanations, explain why the nursing intervention was chosen for the NCP.

Rationales do not appear in regular care plans. They are included to assist nursing students in associating the pathophysiological and psychological principles with the selected nursing intervention.

Step 8: Assessment

Evaluating is a planned, ongoing, and intentional activity that assesses the client’s progress toward achieving goals or desired outcomes, as well as the effectiveness of the nursing care plan (NCP). Because the conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed, evaluation is an essential part of the nursing process.

Step 9: Put it in Writing

The client’s NCP is documented in accordance with hospital policy and becomes part of the client’s permanent medical record, which the oncoming nurse may review. Care plan formats differ between nursing programs. Most are designed to guide the student through the interconnected steps of the nursing process, and many use a five-column format.

Basic Nursing and General Care Plans

Miscellaneous nursing care plans examples that don’t fit other categories:

  • Cancer (Oncology Nursing)
  • End-of-Life Care (Hospice Care or Palliative)
  • Geriatric Nursing (Older Adult)
  • Surgery (Perioperative Client)
  • Systemic Lupus Erythematosus
  • Total Parenteral Nutrition

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