Nursing care plans provide documentation
By their very nature, care plans document every aspect of the patient’s care from assessment to diagnosis, to planned interventions, to outcomes and evaluation. This documentation helps others who are non-medical (social workers, family members, administrators, student interns, etc.) know what is going on with that patient and documents what was and wasn’t done. This system of checks and balances protects patients, nurses, and other members of the interdisciplinary care team.
Nursing care plans address the whole patient
Without the “road map” that the nursing care plans provide, certain important issues are likely to be neglected. Because the care plans are holistic in their focus, they take into account all aspects of the patients, their families, their community experiences, and responses to actual or potential health problems and life processes. Each person along the continuum of care can ensure that all of these important issues are being addressed when a nursing care plan is in place.
Nursing care plans help you gain experience
Even the most seasoned nurses still learn something on the job every day. The documentation and evaluation process of the nursing care plan allows nurses to take stock of their plan and determine if it produced the predicted outcome or if it didn’t work as intended. What was the patient’s response to your intervention? Did you need to adjust your care plan and why?
5 steps to developing nursing care plans
The nursing practice model is based on providing holistic, patient-focused care. At the center of that care is the nursing care plan, which basically consists of five main steps.
Step one: Assessment
The first step in care planning is accurate and comprehensive assessment, followed by regular reassessments as often as the patient’s status demands. What does the patient look like? Why is the patient seeking medical care?
Step two: Diagnosis
The nursing diagnosis is the clinical judgment about the client’s response to actual or potential health conditions or needs. What is the patient’s problem? What is his or her response to a condition?
Step three: Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-term goals for the patient. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.
Step four: Implementation
Nursing care is carried out according to the care plan. All aspects of care are documented in the patient’s record. What were your actions? How often did you carry them out?
Step five: Evaluation
Did the nursing care plan work? Is the care plan still working? Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.
While this seems like a lot of documentation to students, the nursing care plan is much more intuitive when used in professional practice with every patient. It flows naturally into your charting and is a vital part of patient care.
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