.In order to write a perfect nursing care plan, you need a step-by-step approach. This guide explains how to write the best nursing care plan in a comprehensive way. If you are a nursing student and you need help with your nursing assignment, place your order right now to enjoy our expert nursing homework help services.
What is a nursing care plan?
A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks.
Nursing care plans also aid to achieve health care outcomes by providing a way of communication between nurses, their patients, and other healthcare providers. Moreover, the nursing care planning process helps to ensure consistency and quality inpatient care. It begins when a patient is admitted to the agency. It is updated throughout in response to the patient’s changes in condition and evaluation of objectives achievement. In fact, excellence in nursing practice is based on planning and delivering patient-centered care.
Types of Nursing care Plans.
Nursing care plans can be formal or informal.
The formal nursing care plan is a written or computerized guide. It organizes information about the client’s care. Formal care plans are further subdivided into:
- Standardized care plan – They specify the nursing care for groups of clients with everyday needs.
- Individualized care plan – These types of formal care plans are designed to meet the needs of a specific patient or needs that are not addressed by the standardized care plan.
On the other hand, an informal nursing care plan is a strategy of action that exists in the nurse‘s mind.
Importance of a nursing care plan.
- It defines a nurse’s role. It assists nurses to identify their roles in attending to the overall health and well-being of clients without having to rely entirely on a physician’s orders or interventions.
- Provides direction for individualized care of the patient. It assists nurses to think critically and to design interventions that improve the patient’s well-being.
- Continuity of care. It allows patients to receive the most benefit from treatment. This is because nurses from different shifts or different floors can use the data to render the same quality and type of interventions to care for patients.
- Documentation. Nursing care should be well documented. Thus, the NCP can be used to provide evidence that care was provided. Moreover, it should outline which observations to make and what nursing actions to carry out. It should also outline what instructions the patient or family members require.
- Serves as a guide for assigning a specific staff to a specific patient. There are instances when client’s care needs to be assigned to staff with particular and precise skills.
- Serves as a guide for reimbursement. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the patient.
Goals of writing a nursing care plan.
There are several goals of writing a nursing care plan. They include:
- Identifying goals and expected outcomes.
- Reviewing documentation and communication of the care plan.
- Measuring the level of nursing care while supporting holistic care.
- Promoting evidence-based nursing care.
- Rendering pleasant conditions in hospitals.
Components of a nursing care plan.
An NCP usually includes nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales.
- Client health assessment, medical results, and diagnostic reports.
- It outlines the expected patient outcomes.
- Nursing interventions are documented in the care plan.
- Rationale for interventions in order to be evidence-based care.
- Evaluation that documents outcomes of nursing interventions.
Step-by-step guide on how to write a nursing care plan.
1. Data collection.
First of all, creating a patient database using data collection methods is always the first step in writing a nursing care plan. A client’s database includes all the health information gathered.
2. Data analysis.
During this step, you start by gathering enough information about your patient’s health. Then, the next step is to analyze and organize data in order to formulate your nursing diagnoses.
3. Formulating your nursing diagnoses.
Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions.
4. Setting priorities.
This is the process of establishing a preferential sequence for address nursing diagnoses and interventions.
5. Establishing patient’s goals.
After assigning priorities to different situations, the nurse should set goals for each priority. These goals describe what the nurse expects as outcomes of implementing the nursing interventions.
6. Selecting nursing interventions.
Nursing interventions are actions that a nurse performs to achieve a patient’s goals. Interventions should focus on reducing patient’s risk factors.
7. Providing rationale.
It is also known as a scientific explanation. These are the underlying reasons for which the nursing intervention was chosen for the NCP.
This is an important aspect of the nursing process. Conclusions that are drawn from this step help determine whether the nursing intervention should be terminated, continued, or changed.
9. Putting it on paper.
The patient’s NCP is documented according to the hospital policy. Therefore, it becomes part of the patient’s permanent medical record which may be reviewed by the oncoming nurse