A nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the veterinary profession. A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation.
According to UK nurse Helen Ballantyne, care plans are a critical aspect of nursing and they are meant to allow standardised, evidence-based holistic care. It is important to draw attention to the difference between care plan and care planning. Care planning is related to identifying problems and coming up with solutions to reduce or remove the problems. The care plan is essentially the documentation of this process. It includes within it a set of actions the nurse will apply to resolve/support nursing diagnoses identified by nursing assessment. Care plans make it possible for interventions to be recorded and their effectiveness assessed. Nursing care plans provide continuity of care, safety, quality care and compliance. A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid.
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Objective
- To promote evidence-based nursing care and to provide comfortable and familiar conditions in hospitals or health centers.
- To promote holistic care which means the whole person is considered including physical, psychological, social and spiritual in relation to management and prevention of the disease.
- To support methods such as care pathways and care bundles. Care pathways involve a team effort in order to come to a consensus with regards to standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease.
- To record care.
- To measure care.
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History
The function of nursing care plans has changed drastically over the past several decades. In 1953, care planning was not believed to be within the nursing scope of practice. In the 1970s, care planning was activity based. Patients were listed according to the procedures they were having done, which determined their plan of care. Care provided was passed on by word of mouth, dressing books, and work lists. These forms of communication all focus on activities the nurse performed instead of focusing on the patient. Today, nursing care plans focus on the individuals unique set of needs and goals. Care plans are individualized to create a patient-centered approach to care. Therefore, nurses must perform a physical assessment prior to planning a patients care.
Components of a care plan
A care plan includes the following components;
- Client assessment, medical results and diagnostic reports. This is the first step in order to be able to create a care plan. In particular client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic and environmental. Information is this area can be subjective and objective.
- Expected patient outcomes are outlined. These may be long and short term.
- Nursing interventions are documented in the care plan.
- Rationale for interventions in order to be evidence based care.
- Evaluation. This documents the outcome of nursing interventions.
How to write a care plan
- The first step to creating a care plan is performing a full assessment on your patient. Both objective and subjective information will be obtained. This step needs to be completed before beginning any care plan.
- After performing a thorough assessment, the nurse can make a nursing diagnosis based on the data. Based on the data, the nurse will be able to prioritize which problem is most important. To begin, a nursing diagnosis has two or three parts. First, the nurse must pick a standard nursing diagnosis from the official NANDA-I list. Next, is the "related to" (r/t) statement. This is the etiology or cause of the problem. Last, is the "as evidenced by" (aeb) statement. This will be the list of signs and symptoms of the problem that the nurse identified during the assessment. This must be separated by subjective and objective data. To summarize, the first column of the nursing care plan will include the nursing diagnosis. This includes: the NANDA-I nursing diagnosis r/t the etiology aeb signs and symptoms including both subjective and objective data.
- Next, a list of outcomes must be developed. The NOC list may be used to assist in selecting outcomes. NOC has specific outcomes for each NANDA-I nursing diagnosis. When writing the outcomes, remember the acronym SMART. This means that a nursing outcome must be specific, measurable, attainable, realistic, and timed. For example, the outcome, "The patients respiratory rate will improve" is not acceptable. It is not measurable, and there is no time frame. Instead, "The patient demonstrates proper use of incentive spirometer by end of shift" is an acceptable outcome because it is measurable and has a time frame.
- Next, a list of interventions must be developed to accomplish the set outcomes. The NIC list may be used to assist in selecting interventions. NIC has specific interventions for each NANDA-I nursing diagnosis. These interventions may either be independent or collaborative interventions. If the intervention is independent, this means that the nurse can autonomously perform without an order. Some independent interventions are coughing and deep breathing, re-adjusting a patient, and putting pillows underneath a patients arm. If the intervention is collaborative, this means that the nurse must have an order. A collaborative intervention is performing a urinary catheterization. An appropriate nursing intervention for the nursing outcome listed above is, "Teach proper use of incentive spirometer during shift."
- Finally, an evaluation must be performed to assess the interventions. Evaluation continually occurs throughout the nursing process. An evaluation must be performed prior to initiation of interventions to give a baseline. Then, the nurse will reassess the patient after the interventions have been performed. This will allow nurses to ensure that the outcomes are being met. On a nursing care plan, you will rate 1-5 on each outcome for both their baseline and their status after initiation of interventions. For the nursing outcome list above, the baseline would be rated a 1 because the patient has not learned how to use an incentive spirometer. If the patient demonstrates proper use of the incentive spirometer by the end of the shift, that outcome would then be rated as a 5 post-intervention.
Computerised nursing care plans
A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. Using electronic devices when creating nursing care plans are a more accurate, accessible, easier completed and easier edited, in comparison with handwritten and preprinted care plans.
See also
- Nurse scheduling problem
- Omaha System
References
Source of article : Wikipedia
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