Care plans are an essential element of any curriculum developed for the medical profession. Some care plans, like nursing care plans, need detailed attention as they pertain to special care and the needs of the patients. A nursing care plan is a formal process that revolves around identifying the needs of patients and communication between nurses and patients to achieve healthcare outcomes per standard health protocols.
Why Nursing Care Plan?
No one can learn a profession and claim mastery without going through a learning procedure; nursing is not oblivious to that. A person unfamiliar with the nursing profession might assume that nursing is just giving pills and setting up the bed for the patient; still, from a professional perspective, it is more than that. Hospitals need nursing care plans to ensure the continuity of care between different shifts and floors to share the same patient data and observations with fellow nurses and doctors. Nursing care plans are always made, keeping patients in mind, as they should receive physical and psychological help from patients. A nursing care plan also helps as proof of receipt and helps payers in deciding how much they should give for services.
Purposes of Nursing Care Plan
No workable plan is made without purpose as it wouldn’t be effective. Nursing care plans are made to identify the unique role nurses play in the well-being of patients. Each patient is considered as an individual, thus employing that every patient has to be treated on an individual level as per their condition. An active care plan also ensures that nurses treat the patient’s medical situation equally, irrespective of shift and department. A well-implemented care plan also ensures that observations are documented, no document pad, which specific nurse actions have been taken, and what step should be taken next. Doctors can also glance at what medications a patient has taken over time. Insurance companies also ask for the medical record much as they will be covering the insurance policy.
Components of Nursing Care Plan
A successful nursing care plan includes nurses’ diagnoses, client problems, expected results, and nursing interventions from time to time. So, to make a plan that discusses the parameters above, a nursing care plan always starts with assessing the patient.
- Assess the Patient
Knowing your patient’s medical history, lab report, and vital signs is essential to be well aware of in advance as a nurse. A conversation with a loved one or legal representative might also be helpful in the initial assessment. If you take care of these factors and get to see the patient, you will already have familiarized yourself with areas of improvement and any possible risks involved while dealing with the patient.
- Identify Nursing Diagnosis
Without a physician’s order, the nurse can’t perform a diagnosis and other minor invasive procedures. For example, if the patient is complaining of acute pain, insomnia, fever, and risk of falling- they all come under the category of nurse’s diagnosis. The North American Nursing Diagnosis Association (NANDA) has formulated a list that recommends that a nurse can help follow the standard procedures.
- Set Goals for the Patient
Let’s agree that the patient is not in the hospital of their choice. Neither patient wants to spend a long time in the hospital. As a nurse, always set goals and the possible outcomes for each patient within the given time. Results can be assessed based on the lab reports, nursing diagnosis, and by asking patients health-related questions. Goals can be short-term or long-term, depending on the patient’s condition.
- Nursing Interventions
The nurse intervenes from time to time to give medications, educate and give strength to the patient, check on vital signs every couple of hours, and check the patient’s pain levels at different levels to get the possible outcome. All of these nursing interventions come under the nurse’s diagnosis.
- Progression and Evaluation
A proper nursing care plan will be fruitless if it doesn’t see how much progress the patient has made using the nurse’s care plan. If there isn’t any improvement, it implies that the care plan needs to be evaluated first and see whichever component(s) hinders the progress.
A nursing care plan is only successful if the nurses are influential and kind in communication. A nurse should be easy to access and always up to date about the patient’s medical situation. A care plan can only be successful if the nurse is emphatic.