Writing the best nursing care plan involves a step-by-step strategy. To help our student nurses and professional nurses, we have created a comprehensive database of nursing care plans (NCP) and NANDA nursing diagnosis examples. A complete guide on drafting an outstanding nursing care plan or a template for your unit is given.
What is a nursing care plan?
A nursing care plan (NCP) is a structured approach that accurately identifies current requirements and anticipates future needs or dangers. Care plans facilitate communication between nurses, patients, and other healthcare providers to accomplish health care goals. Patient care would suffer quality and consistency without the nursing care planning process.
Nursing care planning begins with the client’s admission to the agency and is updated continuously throughout the client’s stay in response to changes in condition and assessment of goal achievement. Excellence in nursing practice is founded on planning and delivering personalized or patient-centered care.
Types of Nursing Care Plans
Care plans can be formal or informal. An informal nursing care plan is a strategy of action that exists only in the mind of the nurse. A formal nursing care plan is a computerized or written blueprint that organizes the client’s medical information. There are two types of formal care plans: standardized care plans and personalized care plans. Standardized care plans require nursing care for clients with everyday needs. Individualized care plans are created to satisfy the individual needs of a given client or to address desires that are not met by the standardized care plan.
Objectives Of Nursing Care Plans
The following are the objectives and goals of creating a nursing care plan:
- Promote evidence-based nursing care and maintain pleasant and familiar hospital or health center environments
- Support for holistic care that embraces the whole person, including their physical, psychological, social, and spiritual well-being, regarding illness management and prevention.
- Implement initiatives such as care pathways and bundles of care.
- Clearly define and differentiate objectives and expected outcomes.
- Conduct a review of the care plan’s communication and documentation.
- Evaluate nursing care.
Purposes of a Nursing Care Plan
- Defines the function of the nurse. It demonstrates the unique role of nurses in addressing clients’ total health and well-being without relying just on physician instructions or actions. The following are the objectives and significance of nursing care plans:
- Provides instructions for the client’s tailored care. It allows a nurse to think critically about each client and design tailored interventions.
- Consistency of care. Nurses working on different shifts or floors can use the data to deliver the same level of care and type of treatments to clients, ensuring that clients obtain the most benefit from therapy.
- It should state which observations to make, which nursing activities to perform, and which directions to give to the client or family members. If nursing care is not accurately documented in the care plan, no care evidence will be available.
- Acts as a guide for assigning a specific staff member to a particular client. There are times when a client’s care must be given to a staff member with particular expertise.
- Acts as a reference for compensation. Insurance companies utilize the medical record to calculate how much they will pay for the client’s hospital care.
- Identifies the client’s objectives. It benefits nurses and clients by participating in their treatment and care.
Components Of Nursing Care Plan
A nurse care plan (NCP) typically contains nursing diagnoses, client problems, intended outcomes, and nursing interventions and justifications. These components are described in detail below:
- Health assessment of the client, medical records, and diagnostic reports. This is the initial step toward developing a care plan. Client evaluation concerns the following domains and abilities: physical, emotional, sexual, psychological, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. This category contains both subjective and objective data.
- The anticipated client outcomes are described. These may be both long and short-term in nature.
- Documentation of nursing interventions is included in the care plan.
- Justification for interventions to ensure evidence-based care.
- Evaluation. This section contains information about the outcomes of nursing interventions.
Care Plan Formats
Typically, nursing care plan formats are classified or grouped into four columns:
(1) nurse evaluations,
(2) anticipated outcomes and goals,
(3) nursing interventions
Various agencies have a three-column structure, with goals and evaluation in the same column. Other agencies use a five-column layout, one of which has a column for assessment cues.
The paper below contains sample templates for the various nursing care plan forms. Please feel free to edit, amend, and share the template.
Student nurses’ care plans are typically handwritten and include a column for “Rationale” or “Scientific Explanation” following nursing interventions. Rationales are scientific principles that explain why a particular nursing intervention was chosen.