What is Nursing Care Plan? Unlimited Guide, Examples & Writing Tips

Today, nursing is one of the most promising career line in the field of healthcare. A lot of fresh students are now aspiring to take nursing as a bright career. In this field, nursing care plan is a very important thing. In this blog we will give you a guidance on care plan for nurses.

Why Nursing Care Plans Matter in Healthcare Education

A proper nursing care plan is very much essential the field of nursing education since they teach the students to apply the nursing procedure by collecting the patient information and fostering a critical thinking with a holistic care for the patients.

This is done by developing individualized treatment plan for each patient by promoting all communication and team work with a proper documentation and accountability.

What is a Nursing Care Plan? Definition & Purpose

Nursing care plan is a written tool to outline the diagnoses, interventions and goal in the field of nursing healthcare. This care plan is very much useful for the nursing students for utilizing the nursing process.

A nursing care plan is made based on detailed patient data to prioritize the plans, goals and interventions that are liked with specific diseases procedures. A proper nursing care plan is very much needed for establishing a good communication between the nurses and the patients.

Purpose of Nursing Care Plan are as Follows:

Keeping Track of the Patient from Admission to Discharge: A nursing care plan is very much updated as based on the goals, stays and outcome of the patient. It follows the patient across all the care setting and faculty transfers.

Helps you to Plan the Interventions: The care plan provides a structure to the interventions by allowing you to asses the outcome of the interventions as well revise the care based status of the patient.

Monitoring the Health Progress of the Patient: The nursing care plan includes a combination of the shot as well long term goals that are very much timely, measurable and specific. Here, the nurse can always monitor if the interventions are successful and effective in treating the patient.

Establishing Communication Between the Nurses: The nursing care plan is a document to assist the nurses to provide consisting and continuous care for sharing goals.

Coordinating the Disciplines: A nursing care plan might include an input provided by any other interdisciplinary team members to establish a good communication for establishing the health care priorities.

Engaging with the Patient Centered Care: Wherever needed, the patient should be involved to make a care plan. The nursing care plans are the most used to collaborate with the patient and their families in accord of the preference, culture and values of the patient.

Documentation Procedure: The nursing care plan se great opportunities fort the nurses to demonstrate ethical and safe patient care as per professional regulation and guidance. This documentation can be used for proper quality improvement, communication, as well legal proceedings.

Offering a Good Nursing Care: All the patient diagnosis reports are outlines by the nursing care plan. This diagnosis need to align with the NANDA I approved nursing diagnosis by creating an effective communication.

Key Components of a Nursing Care Plan

A proper nursing care plan includes 5 key points and is commonly referred as ADPIE:

• Assessment,
• Diagnosis,
• Planning (setting outcomes/goals),
• Implementation (interventions),
• Evaluation.

This is a structured process that helps the nurses to collect all the patient data to identify their health issues and set proper medical goals and regimes to cure them.

The nursing care planning process key components are elaborated below:

Assessment: It is the first step that involves gathering all the patient data via thorough observations of the medical history, conversations, lab results, etc.

Diagnosis: It is based on the assessment data and the nurses can identify the major health problems of the patient in terms of medical protocols.

Planning: In this stage, you need to set all the measurable achievements with a relevant bond of time for desired outcome of the patient health.

Implementation: A nurse always need to carry out all the planned nursing interventions with specific actions to get the desired goals.

Evaluation: Here, the nurse assesses the health progress of the patent to achieve the best health care goals.

Types of Nursing Care Plans

Informal vs. Formal

Informal Care Plan:

• These are the mental plans as developed by the nurses to address the urgent needs of the patient.
• Often they are thought on of the spot and are not much documented
• These are often involved in making very quick decision as based on the present health condition of the patient.

Formal Care Plan:

• These are the computerized or written pans to serve as a guide to patient healthcare.
• This pan is documented and contains detailed information regarding the patient with nursing interventions and all the possible outcomes.
• They help the nurses to organize as well coordinate the patient care information for all the members of the health care team.

Standardized vs. Individualized

Standardized Care Plan:

• These are the pre-written plans that are based on the needs of any patient group with similar conditions and diagnosis.
• These always provide a very formal network for a good care delivery to the patients.
• These are mostly done for the post-surgery patients

Individualized Care Plan

• It is always tailored for the individual needs of the patient. This includes their spiritual, emotional and physical needs.
• This also involve a very holistic approach by building upon a very standard guidelines as well considering the history, personal preferences and health status.
• In this car plan you need to value the patient need very highly and need to adhere to it.

Benefits of Nursing Care Plans for Students and Professionals

The nursing care plan benefits the students by providing a perfect framework for integrating the theory practice with developing the critical thinking and learn all the patient centered care techniques. It is elaborated as below:

For the Nursing Students:

• Developing the Critical Thinking Skills: The nursing care plans need the students to analyses the patient data, nursing diagnoses, and plan all the possible interventions.
• Links Theory and Practice: These serve as a major tool to apply all the theoretical knowledge as learned in your class room a well practical life scenario.
• Triggers Patient Centered Care: You will learn to address all the holistic needs of the patients by considering their psychological physical, social and spiritual aspects.
• Promoting Confidence: Via continuous practices as well feedback you can build skills as well confidence that are required for quality care.

For the Nursing Professionals:

• Enhancing Communication: The nursing care plans act as a guide map to ensure all the healthcare members are on one page and are working to get the treatment goals.
• Ensuring Safety and Quality: By starting the planed interventions the care plans can reduce a lot of errors. It can also prevent the gaps in patient care.
• Facilitates the Legal Documents: A good nursing care plan gives a detailed and formal record of the provided care. This is always very much essential for the legal protection of the patient care and documentation.
• Supporting the Care Continuity: The nursing care plans always provide a very consistent, updated information during the shifts changes and the hand offs of the patient. This supports a continuous patient care.
• Promotes a Good Care: The care plans help the nurses to organize all the major patient information, top needs as well coordinating the interventions to lead a better care regimen.
• Empowers Patient with his Family Involvement: It always provides very clear goad to encourage a good involvement with the patient as well his family with the nurses as well other health care providing team.

Step-by-Step Guide: How to Write a Nursing Care Plan ?

What are the Steps in Nursing Care Plan?

Step 1: Collect Patient Data

It is the very first step of writing a nursing care plan for the patient. It involves data collection and critical thinking. Many healthcare organizations use certain distinct formats to assess the phase.

The collected data here might be statements, verbal or objective. Sources of these data can be the patient’s family or friends. You can also collect data from the vital signs of the patient, comeliness, symptoms, medical history, etc.

Step 2: Identify Nursing Diagnosis

By using the collected data you can always develop any nursing diagnosis from the NANDA nursing care plan examples. A medical diagnosis in nursing from the very basis of selecting the right nursing actions to meet the desired outcomes.

Step 3: Set SMART Goals:

While you are learning how to write a nursing care plan, this stage follows a proper diagnosis. Here, you need to prepare the SMART goals as based on the evidence-based practice (EBP) guidelines.

Step 4: Plan Interventions:

After setting the patient goals you need to implement the actions to support the patient in achieving their goals. This implementation nursing stage includes performing all types of interventions that are outlines in the nursing care plan.

Here, you need to follow the order of the doctors for the nursing interventions. These interventions can be behavioral, family, psychological, complex, heath, safety, etc.

Step 5: Evaluation:

It is the final stage of the nursing care plan where the doctor or nurse can evaluate ted sired care outcome for the patient.

Step 6: Evaluate and Revise:

Finally, you need to do a very though revision of everything you Have dine in order to make it absolutely flawless.

Nursing Care Plan Example (With Diagnosis, Goals, and Interventions)

The Nursing care plans examples as written by the students are not as same as the professional nurses in practical settings. The student version is much longer and contain more details.

In the Nursing care plan examples for nursing students, you need to write all the vital signs of the patient in the intervention section like blood pressure, blood sugar, pulse rate, heart rate, oxygen level, body temperature, etc.

As a nursing student, if you write a detailed information, it will strengthen your nursing training course. Writing a good nursing care plan example can be bit time consuming for the students.

Thu, you always need to master the information in your nursing school for improving your competency.

Common Mistakes Students Make in Nursing Care Plans

• Focusing on writing diagnosis
• Valuing the unrealistic goals
• Incomplete assessments
• Less individual care
• Lack of proper updating of the nursing care plan
• Issues with the time management
• Lack of communication and coordination in between all the members of the healthcare team
• Lack of communication with the doctors
• Relying on the inappropriate sources

Best Tips to Improve Your Nursing Care Plan Writing

• Adapt a patient centered approach
• Coordinate well with your team members
• Communicate well with the doctors
• Follow the NANDA Nursing care plan PDF
• Focus on your critical thinking
• Coordinate well with your patient
• Keep yourself updated
• Focus on educating your patient regarding the treatment plan
• Carry out a good assessment on the general health of your patient
• Follow the SMART goals
• Outline and structure the whole nursing care plan before implementing it
• Implement the care plan very much properly and appropriately
• Focus on your nursing interventions and implement them in the best possible way to achieve the treatment goals of your patient

Conclusion: Mastering Nursing Care Plans for Academic & Clinical Success

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Author Bio:

 

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