Nursing care plans are an important part of providing quality patient care. The care plans record the outcome of the discussion between the patient and the health-care professional and list any actions agreed. Care plans also help to define the nurses’ role in the patient’s treatment and specific goals for an individual patient.
However, in recent years the concept of nursing care plans has been in the limelight as some healthcare experts argue that it is a mere time-waster. Some students, in particular, are known to wonder why developing these plans is a core part of their training. However, while embracing this culture may seem like a hectic task, there are solid studies that show that it indeed has lots of benefits. In addition, there are many tangible reasons why planning can improve the quality of healthcare. Let us have a look at what it takes to create nursing care plans and their benefits.
- Steps to Developing a Nursing Care Plan
- Characteristics of Quality Nursing Care Plans
- Why Nursing Care Plans Are Important
- Nursing Care Plans Examples
- Nursing Care Plans — Goal Statements
- Nursing Care Plans — Nursing Interventions
Steps to Developing a Nursing Care Plan
The purpose of creating professional nursing care plans is to identify problems of a patient and find solutions to the problems. This is usually done basically in five main steps including assessment, diagnosis, planning, intervention, and evaluation.
Step One: Assessment
The first step involves comprehensive and accurate assessment. This is usually accompanied by a routine assessment of the patient’s health status demand. For a comprehensive assessment, you should ask yourself questions such as: Why is the patient seeking medical care? What is the overall look of the patient?
Step Two: Diagnosis
Also referred to as a diagnostic statement, nursing diagnosis involves professional judgment concerning the patient’s response to either potential or actual health problems or needs. It, therefore, acknowledges the potential or actual health condition and labels it. Some questions nurses should ask themselves at this stage include: What problem is the patient facing? How does the patient response to particular conditions? The answers to such questions should lie in the assessment data for nursing care plans.
Step Three: Planning
At this stage, the nurse usually sets achievable short term and long term targets for the individual patient in line with the diagnosis and assessment. The goals should also be verifiable by someone else so the nurses that read your care plan know exactly what has been achieved. The nurse normally puts what he or she would like to see from the patient may be by the end of her shift, clinical week or whatever the time frame is. For example, if your patient is in so much pain and you rate her pain as a 9 on a scale of 1-10 and you want her, by the end of the day, to rate it as 4. This is a very measurable, verifiable and achievable goal. The goals, assessment data, and diagnosis are all written in the individual care plan in order for the nurses and other healthcare practitioners to access it.
Step Four: Intervention
Nursing care intervention is instituted based on the structure and components of a projected care plan. This process is usually based on the documented patient’s records. The goal is to ensure that the selected intervention helps solve or minimizes the patient’s existing condition.
Step Five: Evaluation
This stage focuses on the status of the patient and the overall effectiveness of the care process in a bid to modify the overall nursing care plan as may be needed. However, the evaluation column cannot be filled out until you have completed your interventions. The question here are the following: How did the patient respond to your intervention? Were your goals accomplished? If you didn’t, was the goal unrealistic for the patient? Is the plan still working or do you need to change a couple of things, why? The purpose of this stage is to help you learn what works best with different types of patients so that you can better take care of the next patient down the line with same conditions.
Characteristics of Quality Nursing Care Plans
- It is based upon identifiable health and nursing problems.
- It focuses on actions which are designed to either solve or reduce the existing problem.
- It usually relates to the future.
- Nursing outcome classifications with specified outcomes to be achieved by the nurse including deadlines.
- It is a product of a deliberate systematic process
According to data from the US Department of Health and Human Services, there is a growing demand for full-time registered nurses to provide adequate patient care. This need is anticipated to balloon to 2.8 million by 2020 leaving an estimated shortage of 1 million professionals. By extension, this means that we need to invest in professional education so as to enhance the effectiveness of our current crop of nursing experts which is why training on nursing care plans is deemed important.
Through nursing care plans, nurses are able to continually asses, implement, diagnose and evaluate the progress of a patient. In the past, documentation of the care plan has been a time-consuming process, but thanks to the advent of computerized data systems, this crucial process has been streamlined to provide greater efficiency. This high level of efficiency has alleviated some of the pains worsened by nursing shortages with much broader areas of potential still existing.
In one study, 20 nurses were formally interviewed and a variety of questions regarding the benefits of using a computerized nursing plan system were raised. The results of this study showed that in addition to the expected response of streamlined care, nurses reported additional benefits in several other areas. These include:
- Better reference for nurse’s memory of patient details
- Learning tool for patient care
- Vehicle for easily modifying care plan content
These benefits highlight the creative potential for nursing care plans, particularly when integrated with IT solutions.
Moreover, information included in a typical nursing care plan usually involves the anticipated care that a nurse will provide for an individual patient in line with specifically identified patient problems. In other words, these plans serve as an intermediary stage of nursing process connecting the initial evaluation with the final outcome.
As such, given its central role in healthcare, it would appear obvious that nursing care plans knowledge offers great potential in a variety of areas in addition to making care more efficient.
There are different types of nursing care plans as developed by different RNs for different conditions. For instance, you can find plans for hypertension, pain, diabetes, pneumonia or even nursing care plan for dementia. Here we share an example of nursing care plan for diabetes which can help give you an idea on how to go about creating NANDA nursing care plans.
NANDA Nursing Care Plan Diagnosis (Problem Statement) – Imbalanced nutrition and excessive intake of nutrients as evidenced by Type II Diabetes.
1.Patient to acknowledge their behaviors and feelings that exacerbate improper nutrition within 8 hours. (Short-term goal statement).
2.Patient to design a diet plan which will realistically help them adjust caloric intake within 24 hours. (Realistic is the keyword).
3.Patient to incorporate 30 minutes of exercise (Well-tolerated) into daily schedule within 48 hours. (Short-term goal statement with long-term goal of lifestyle change).
- The nurse will have to explain and engage the patient in verbalizing the relationship between diet and diabetes. The nurse will also give a return (detailed) explanation in his/her own choice of words.
- Patients shall consult with dietitians to identify their optimal caloric intake, activity level, and potential.
- Patient to keep a journal for tracking caloric intake for food items consumed.
- A patient shall display a clear working knowledge of reading food labels after nurse demonstrates (you choose how).
- Promote caregiver or family member participating in the healthy lifestyle routine as recommended in nursing care plans.
- The nurse will keep a record of the patients exercise long to enhance accountability.
- Patients shall have a schedule of goals and targets particularly for those targets related to reducing overall intake of calories.
Comments: The most vital thing to remember when dealing with type 2 diabetes is that healthy living can completely negate the diabetic disease process. Research has shown that human behavior dictates whether the problem exacerbates or not. Lack of proper nutrition and physical activity can lead to type 1 diabetes which has more severe symptoms including premature death, vision loss, and neuropathy.
As we have said, there are many ways to approach nursing care plans but you should not get confused with the minor details. You only need to follow the structure provided above and combined with a bit of training the otherwise involving task can easily prove to be a profitable undertaking. The end goal of this entire engagement is to simplify a nurse’s professional life, enhance productivity and improve the overall quality of healthcare.