Nursing care plan

A nursing care plan provides direction on the type of nursing care the individual/family/community may need.[1] The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care.[2] Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the veterinary profession.[2] A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation.[2]

According to UK nurse Helen Ballantyne, care plans are a critical aspect of nursing and they are meant to allow standardised, evidence-based holistic care.[2] It is important to draw attention to the difference between care plan and care planning.[2] Care planning is related to identifying problems and coming up with solutions to reduce or remove the problems.[1] The care plan is essentially the documentation of this process.[1] It includes within it a set of actions the nurse will apply to resolve/support nursing diagnoses identified by nursing assessment. Care plans make it possible for interventions to be recorded and their effectiveness assessed.[2] Nursing care plans provide continuity of care, safety, quality care and compliance. A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid.

Objective

  1. To promote evidence-based nursing care and to provide comfortable and familiar conditions in hospitals or health centers.[1]
  2. To promote holistic care which means the whole person is considered including physical, psychological, social and spiritual in relation to management and prevention of the disease.[1]
  3. To support methods such as care pathways and care bundles. Care pathways involve a team effort in order to come to a consensus with regards to standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease.[1]
  4. To record care.[1]
  5. To measure care.[1]

History

The function of nursing care plans has changed drastically over the past several decades. In 1953, care planning was not believed to be within the nursing scope of practice.[3] In the 1970s, care planning was activity based.[3] Patients were listed according to the procedures they were having done, which determined their plan of care.[3] Care provided was passed on by word of mouth, dressing books, and work lists.[3] These forms of communication all focus on activities the nurse performed instead of focusing on the patient.[3] Today, nursing care plans focus on the individuals unique set of needs and goals.[3] Care plans are individualized to create a patient-centered approach to care.[4] Therefore, nurses must perform a physical assessment prior to planning a patients care.[4]

Components of a care plan

A care plan includes the following components;

  1. Client assessment, medical results and diagnostic reports. This is the first step in order to be able to create a care plan. In particular client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic and environmental. Information is this area can be subjective and objective.[5]
  2. Expected patient outcomes are outlined. These may be long and short term.[5]
  3. Nursing interventions are documented in the care plan.[5]
  4. Rationale for interventions in order to be evidence based care.[5]
  5. Evaluation. This documents the outcome of nursing interventions.[5]

Computerised nursing care plans

A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process.[6] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions.[6] Using electronic devices when creating nursing care plans are a more accurate, accessible, easier completed and easier edited, in comparison with handwritten and preprinted care plans.[6]

See also

References

  1. 1 2 3 4 5 6 7 8 Hooks, Robin (2016). "Developing nursing care plans". Nursing Standard. 30 (45): 64–65. doi:10.7748/ns.30.45.64.s48. PMID 27380704.
  2. 1 2 3 4 5 6 Ballantyne, Helen (2016). "Developing nursing care plans". Nursing Standard. 30 (26): 51–60. doi:10.7748/ns.30.26.51.s48. PMID 26907149.
  3. 1 2 3 4 5 6 Ballantyne, Helen (2016). "Developing nursing care plans". Nursing Standard. 30 (26): 51–57 – via ProQuest.
  4. 1 2 Doenges, Marilynn (2014). Nursing Care Plans : Guidelines for Individualizing Client Care Across the Life Span. Philadelphia: F. A. Davis Company. ISBN 9780803640900.
  5. 1 2 3 4 5 Doenges, Marilynn; Moorehouse, Mary; Murr, Alice (2014). Nursing care plans: guidelines for individualizing client care across the life span (9th ed.). Philadelphia: F.A. Davis Company. ISBN 9780803640900. OCLC 874809931.
  6. 1 2 3 Thoroddsen, Asta; Ehnfors, Margareta; Ehrenberg, Anna (October 2011). "Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records". Computers, Informatics, Nursing: CIN. 29 (10): 599–607. doi:10.1097/NCN.0b013e3182148c31. PMID 22041791.
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