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How to Create an Effective Nursing Care Plan
- A nursing care plan serves as the basis for administering, maintaining, and evaluating the effectiveness of positive patient outcomes.
- Also known as “plan of care”, nursing care plans are comprised of a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation. This system ensures continuity of care so that various staff working various shifts can gauge progress and continue where the last shift left off.
- Electronic documentation systems can make this process a lot easier with automation but must be reviewed and customized when appropriate.
MSN, RN – Chief Nursing Officer
Nursing care plans serve as the basis for administering, maintaining, and evaluating the effectiveness of positive patient outcomes. They serve as an integral part of each patient’s care. The nursing care plan (or plan of care as it is sometimes called) should be adjusted and evaluated on an ongoing basis from the beginning of a patient’s care until the time of discharge and beyond.
Many nurses struggle with the proper way to create an effective nursing care plan and making necessary adjustments that reflect how goals are being managed in an effective way.
Importance of a Nursing Care Plan
Nursing care plans ensure consistency of care among patients. If a robust nursing care plan is in place, staff from different shifts, facilities, or various medical providers can use the information to give the same quality of care and support if needed.
In turn, this allows people to receive a high standard of safe, effective, and responsive care in a service which is managed well and followed consistently. The care plan should serve as a guide to ensure that total and effective care is being granted to each patient.
Continuity of care is also attained and achieved when all team members have access to the plan of care and revisions are made as care needs change.
Five Components of a Nursing Care Plan
Nurses often ask how to begin a nursing care plan and how to ensure that it is formulated correctly. The following five components serve as a guide to correctly create a nursing care plan without missing any of the necessary elements.
Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation:
- Assessment – the first step to writing a care plan is to perform a detailed patient assessment
- Make a diagnosis – based on the patient’s current medical issues taking place, diagnoses are formulated. The official definition of the term nursing diagnosis from the NANDA-I website is a “clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community”. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability.
- Set goals and outcomes – nursing care plans must have goals and intended outcomes in place in order for positive results to occur
- Determine nursing interventions/implementation – interventions that correlate with the diagnoses must have interventions or plans of action in place that serve as guidelines on how to effectively meet each goal
- Evaluate the plan – evaluating the nursing care plan at initial assessment, during care, and upon discharge is essential to determine if goals are being met and if interventions need to be revised
Reviewing a Care Plan
A nursing care plan should be reviewed on a regular basis typically once a month or more often to ensure sure that any changes have been recorded in the care plan. Care plans that are not reviewed on a regular basis can become messy and difficult to navigate when there is a lack of accurate and up to date information.
A patient’s status can change and diagnoses can vary based on conditions that improve, worsen, or present themselves as a totally different concern.
A care plan that is not routinely reviewed and updated can ultimately lead to poor patient outcomes and quality medical care that is not being maintained consistently. The goal of nurses should be to improve patient care and outcomes and to not regress in these important areas
Sample Nursing Care Plan
The sample nursing care plan is divided into four columns that include the nursing diagnosis, goals and outcomes, interventions, and evaluation. Each patient may have a varying number of nursing diagnoses based on their needs but each of these columns must be included. By using this format, consistency and accuracy is included and ensures continuity of care.
Each nurse should be thinking about these four areas when assessing their patients to formulate the nursing care plan and to ensure that the plan is not only created for the sake of completion, but rather to be utilized to achieve positive patient outcomes.
Despite the idea that nursing care plans can be difficult to formulate, the nurse must keep in mind the importance they serve and how the goals set forth in the plans are to be used for progression among the patients.
The care plan serves as a guideline for other team members to follow. With varying shifts and staff, it is imperative that nurses strive to complete nursing care plans effectively for patient progression. Nursing care plans do require critical thinking skills, but with the entire team working together cohesively, the end results are favorable for the patient.
The Bottom Line
Many facilities now use electronic documentation systems and possess the capability to assist nurses in formulating a nursing care plan with interventions, rationales, and outcomes. Due to many electronic documentation systems being implemented, the stress of creating a nursing care plan has lessened to some degree allowing nurses to enter the important data and the results are then formulated.
Even though many electronic documentation systems are extremely useful, it is important for the nurse to review the auto-formulated care plans to ensure accuracy.
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