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]The Care Plan includes the following components; assessment, diagnosis, expected outcomes, interventions, rationale and evaluation.^[2] According to 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. Nursing care plans promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid.

Objective

1. To promote evidence-based care^[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]

Characteristics

1. Its' focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.^[1]
2. It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.^[3]
3. It focuses on client-specific nursing outcomes that are realistic for the care recipient.^[3]
4. It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.^[3]
5. It is a product of a deliberate systematic process.^[1]

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.^[3]
2. Expected patient outcomes are outlined. These may be long and short term.^[3]
3. Nursing interventions are documented in the Care Plan.^[3]
4. Rationale for interventions in order to be evidence based care.^[3]
5. Evaluation. This documents the outcome of nursing interventions.^[3]

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.^[4] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. ^[4]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.^[4]

See also

• NANDA
• Nurse scheduling problem
• Nursing Interventions Classification
• Nursing Outcomes Classification
• Omaha System

References