How To Write A Nursing Care Plan
Nursing care plans is a formal means of communication
among the nurses, their patients, and other healthcare provides to deliver and
achieve quality healthcare results. It also involves the identification of
existing needs and recognizing the potential needs or risks. Without a
comprehensive nursing care plan process, the quality and consistency in
delivering quality care would be gone.
Nursing care planning starts once the patient is
admitted to a healthcare center and it is constantly updated throughout
according to the patient's change in condition and assessment of goal
attainment. Therefore, planning and delivering customized or patient-centered
care is the basis for excellence in nursing practice.
What is the Purpose of a Nursing
Care Plan?
Nursing care plans are part of
the core curriculum in almost all nursing schools. However, most nurses often
complain that despite the rigorous effort and time spent in learning how to
create a nursing care plan, they rarely do it once they are in the nursing
profession. But what is the purpose of learning to write a care plan and to
what end do they serve?
·
Define a nurse's role: Care plans help in
identifying the unique role of nurses in attending the overall health and
well-being of patients without having to rely entirely on the doctor’s
interventions or orders.
·
Guide customized care of
the patient: Nursing care plans allow the nurse to think critically about each
patient and how to develop interventions that are uniquely tailored to that
particular patient.
·
Continuity of Care: It allows nurses from
different shifts or floors to use the data to render the same quality and kind
of interventions to care for patients. This ensures students get the most out
of treatment by different nurses.
·
Documentation: Nursing care plans
outline what nursing actions to execute, which observations to make, and what
instructions the patient or loved ones require. If nursing care is not
documented in the care plan, then there is no proof that care was provided.
·
Define patient goals: Nursing care plans not
only benefit nurses but also the patients by involving them in their treatment
and care.
·
Serves as a guide for
assigning a specific nurse to a specific patient: There is a time when a patient's care
needs to be assigned to a nurse with specific and precise skills for better
handling and care.
For students, there is a need to be taught how to
individualize patient care, think critically, and how to work towards attaining
the desired outcomes in the nursing process. And knowing how to write nursing
care plans is the first step.
How to Write a Nursing Care Plan
To create an
executable care plan, the following steps should be followed:
1.
Assessing the Patient
A good care plan starts by reviewing all the relevant
data, medical history, vital signs, conversations with the patient and their
loved ones, lab results, observations from other care team members, and
demographic information.
With this information, you can assess the patient’s
emotional, physical, psychological, spiritual needs, risk factors, and areas
for improvement.
2.
Identify and list nursing
diagnoses
After an extensive assessment, identify and list
nursing diagnoses that you can handle without the physician intervention. This
may include acute pain, fever, and risks for falls.
3.
Set goals for the patient
By answering the question, what the desired outcomes
are, you will be able to set the goals.
The answer to this question is entirely based on the assessment, nursing
diagnosis, and feedback from the patient. Ideally, involve the patient in
setting reasonably achievable goals. The goals can either be short-term or
long-term.
4.
Implement nursing
interventions
These are actions taken by the nurse to attain the
desired patient goals and outcome which may include giving medication, checking
for vital signs regularly, assessing the patient’s pain levels at specific
intervals. Moreover, this is where you
should document care as you execute the interventions, including the dependent
nursing interventions as ordered by the doctors.
5.
Evaluate progress and
change the care plan accordingly
You can evaluate the patient and the care plans
regularly to find out whether the nursing interventions are indeed helping the
patient achieve their goals and desired outcomes or should they be changed,
modified, continued, or terminated.
Knowing how to write nursing care plans is an
important part of your responsibilities as a registered nurse. The key is to be
as detailed and precise as possible and use the resources available to help
you. Should you need help in writing care plans, Nursing
Care Plan Writing Services is readily available to help!
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