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What is a nursing care plan?A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost. Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice. Types of Nursing Care PlansCare plans can be informal or formal: An informal nursing care plan is a strategy of action that exists in the nurse‘s mind. A formal nursing care plan is a written or computerized guide that organizes the client’s care information. Formal care plans are further subdivided into standardized care plans and individualized care plans: Standardized care plans specify the nursing care for groups of clients with everyday needs. Individualized care plans are tailored to meet the unique needs of a specific client or needs that are not addressed by the standardized care plan. ObjectivesThe following are the goals and objectives of writing a nursing care plan:
Purposes of a Nursing Care PlanThe following are the purposes and importance of writing a nursing care plan:
ComponentsA nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales. These components are elaborated below:
Care Plan FormatsNursing care plan formats are usually categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. Some agencies use a three-column plan wherein goals and evaluation are in the same column. Other agencies have a five-column plan that includes a column for assessment cues. 3 Column Care Plan Template A 4-column care plan format Below is a document containing sample templates for the different nursing care plan formats. Please feel free to edit, modify, and share the template. Download: Printable Nursing Care Plan Templates and Formats Student Care PlansStudent care plans are more lengthy and detailed than care plans used by working nurses because they are a learning activity for the students. Student nursing care plans are more detailed. Care plans by student nurses are usually required to be handwritten and have an additional column for “Rationale” or “Scientific Explanation” after the nursing interventions column. Rationales are scientific principles that explain the reasons for selecting a particular nursing intervention. Writing a Nursing Care PlanHow do you write a nursing care plan (NCP)? Just follow the steps below to develop a care plan for your client. Step 1: Data Collection or AssessmentThe first step in writing a nursing care plan is to create a client database using assessment techniques and data collection methods (physical assessment, health history, interview, medical records review, diagnostic studies). A client database includes all the health information gathered. In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formulate a nursing diagnosis. Some agencies or nursing schools have specific assessment formats you can use. Step 2: Data Analysis and OrganizationNow that you have information about the client’s health analyze, cluster, and organize the data to formulate your nursing diagnosis, priorities, and desired outcomes. Step 3: Formulating Your Nursing DiagnosesNANDA nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses. We’ve detailed the steps on how to formulate your nursing diagnoses in this guide: Nursing Diagnosis (NDx): Complete Guide and List Step 4: Setting PrioritiesSetting priorities deals with establishing a preferential sequence for addressing nursing diagnoses and interventions. In this step, the nurse and the client begin planning which nursing diagnosis requires attention first. Diagnoses can be ranked and grouped as having a high, medium, or low priority. Life-threatening problems should be given high priority. A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved, such as self-esteem and self-actualization. Physiological and safety needs provide the basis for implementing nursing care and nursing interventions. Thus, they are at the base of Maslow’s pyramid, laying the foundation for physical and emotional health. Maslow’s Hierarchy of Needs
The client’s health values and beliefs, priorities, resources available, and urgency are factors the nurse must consider when assigning priorities. Involve the client in the process to enhance cooperation. Step 5: Establishing Client Goals and Desired OutcomesAfter assigning priorities for your nursing diagnosis, the nurse and the client set goals for each determined priority. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement. Example of goals and desired outcomes. Notice how they’re formatted/written.One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are often used interchangeably. According to Hamilton and Price (2013), goals should be SMART. SMART goals analysis strategy stands for – Specific, Measurable, Attainable, Realistic, and Time-Bound goals.
Hogston (2011) suggests using the REEPIG standards to ensure that care is of the highest standards. By this means, nursing care plans should be:
Short Term and Long Term GoalsGoals and expected outcomes must be measurable and client-centered. Goals are constructed by focusing on problem prevention, resolution, and rehabilitation. Goals can be short-term or long-term. Most goals are short-term in an acute care setting since much of the nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for clients who have chronic health problems or live at home, nursing homes, or in extended-care facilities.
Components of Goals and Desired OutcomesGoals or desired outcome statements usually have four components: a subject, a verb, conditions or modifiers, and a criterion of desired performance. Components of goals and desired outcomes in a nursing care plan.
When writing goals and desired outcomes, the nurse should follow these tips:
Step 6: Selecting Nursing InterventionsNursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. As for risk nursing diagnoses, interventions should focus on reducing the client’s risk factors. In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step. Types of Nursing InterventionsNursing interventions can be independent, dependent, or collaborative: Types of nursing interventions in a care plan.
Nursing interventions should be:
When writing nursing interventions, follow these tips:
Step 7: Providing RationaleRationales, also known as scientific explanations, explain why the nursing intervention was chosen for the NCP. Sample nursing interventions and rationale for a care plan (NCP)Rationales do not appear in regular care plans. They are included to assist nursing students in associating the pathophysiological and psychological principles with the selected nursing intervention. Step 8: EvaluationEvaluating is a planned, ongoing, purposeful activity in which the client’s progress towards achieving goals or desired outcomes and the effectiveness of the nursing care plan (NCP). Evaluation is an essential aspect of the nursing process because conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed. Step 9: Putting it on PaperThe client’s care plan is documented according to hospital policy and becomes part of the client’s permanent medical record which may be reviewed by the oncoming nurse. Different nursing programs have different care plan formats. Most are designed so that the student systematically proceeds through the interrelated steps of the nursing process, and many use a five-column format. Nursing Care Plan ListThis section lists the sample nursing care plans (NCP) and NANDA nursing diagnoses for various disease and health conditions. They are segmented into categories: Basic Nursing and General Care PlansMiscellaneous nursing care plans examples that don’t fit other categories: Surgery and Perioperative Care PlansCare plans that involve surgical intervention. Cardiac Care PlansNursing care plans about the different diseases of the cardiovascular system: Nursing care plans (NCP) related to the endocrine system and metabolism: GastrointestinalCare plans (NCP) covering the disorders of the gastrointestinal and digestive system: GenitourinaryCare plans related to the reproductive and urinary system disorders: Hematologic and LymphaticCare plans related to the hematologic and lymphatic system: Infectious DiseasesNCPs for communicable and infectious diseases: IntegumentaryAll about disorders and conditions affecting the integumentary system:
Maternal and Newborn Care PlansNursing care plans about the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing: Mental Health and PsychiatricCare plans for mental health and psychiatric nursing: MusculoskeletalCare plans related to the musculoskeletal system: NeurologicalNursing care plans (NCP) for related to nervous system disorders: OphthalmicCare plans relating to eye disorders:
Pediatric Nursing Care PlansNursing care plans (NCP) for pediatric conditions and diseases: RespiratoryCare plans for respiratory system disorders: References and SourcesRecommended reading materials and sources for this NCP guide:
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