Whether you are a seasoned nurse or a new nursing student stepping into clinical practice, when it comes to patient care, the difference between good and great lies in one of the most important tools and that is nursing care plan. Nursing care plans are the important part of patient care, as it consists of detailed and organized information that guides the nurses to provide individualized patient care. Writing an effective care plan is important to provide high quality care to the patient. Now let us discuss the components, types, and importance of nursing care plan in detail.
Components of Nursing Care Plan
Nursing care plans are a systematic approach towards patient care that consists of the following components. Details of each component are given below:
- Assessment
- Nursing diagnosis
- Goals
- Interventions
- Rationale
- Evaluation
Assessment
Collecting information about patient’s health through physical examination, questions, observation, and medical history is the first step of nursing care plans. This step is called assessment. There are two types of data or information that is collected during assessment.
Objective data: The objective data is measurable such as collecting vital signs, blood pressure and more.
Subjective data: This information or data is not measurable, and the information is provided by the patient such as what their symptoms are, how they are feeling etc.
Nursing Diagnosis
The next step in nursing care plan is Nursing diagnosis. According to North American Nursing Diagnosis Association (NANDA) defines as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.” Using subjective and objective data, nurses make diagnosis and identify patient’s health problems. Nursing diagnosis consists of the following components:
Nursing care plan example of Surgical incision infection
Problem: It consists of the patient’s problem or potential risk such as risk of infection.
Factors related to the problem: The factors that are related to causing the problem such as infection due to surgical incision.
Sign and symptoms: The signs and symptoms that support the diagnosis such as redness, pus, or pain.
Goals
After assessment and diagnosis nurses prepare SMART (Specific, Measurable, Achievable, Realistic and Time bound) goals which are the planning stage. These goals are set to achieve the desired outcomes. There are two types of goals that can be achieved which are:
Short-term goals: Short term goal is that the patient will report the decrease in pain level to 2/10 in the next 48 hours due to the pain medications that are administered to the patient.
Long term goals: Long term goal is that there are no signs of infection such as redness or pus in the incision site after the medications in next 1 month.
Learn more about SMART goals in our blog.
Interventions
The next step in nursing care plan is intervention. This means the steps or actions the nurse will take to achieve these goals. There are three types of interventions which are:
Independent: The actions taken by the nurse independently without the help of the physician such as wound care, dressing change.
Dependent: The actions that need physician order before the nurse can implement them such as prescription of antibiotics.
Interdependent: Interdependent decisions or actions are made through collaboration between nurses and other healthcare workers. Such as nursing, asking the wound care expert about specialized dressing or asking nutritionists about the diet that can help with healing process.
Rationale
Rationale in nursing care plan means each action or intervention taken during the process should have specific explanation that why this action was taken. It is evidence that supports the nurse’s intervention or action.
For example, for surgical incision infection (nursing care plan example) the following are the rationale for the actions taken.
- Proper wound care will help in reducing the risk of infection and promote sterile environment.
- Administering anti biotics will help combat bacterial infections that will help in healing process of the infection.
- Asking wound care experts about dressing ensures quick healing strategies.
- Asking nutritionists about what food will heal the process faster as it can help in regeneration of the tissues.
Evaluation
This step in nursing care plan indicates to see if the goals have been met to get the desired outcome or not. If not, then the nursing care plan is adjusted. The evaluation consists of the following steps.
Reassessment: Monitoring patients to see the changes and progress. For example, the pain of the patient is getting better or not.
Comparison: Comparing the actual outcomes with the goals such as did the patient’s pain level decrease to 2/10 or not.
Goal achievement: To determine whether the goals are achieved or not. For example, the pain is still there, or it is partially gone or is it gone completely.
Documentation
The documentation in nursing care plan means record of the detailed information of the patient’s health such as initial assessment, nursing diagnosis, interventions, progress and change in care plan if there was any.
Types of nursing care plans
There are 3 types of nursing care plans.
- Standardized care plans: These are prewritten templates for common symptoms or conditions.
- Individualized care plans: This nursing care plan is tailored to meet the unique needs of the patient.
- Collaborative care plans: Multiple healthcare workers collaborate to make a nursing plan according to the patient’s needs that will help his recover.
Importance of nursing care plan
Nursing care plan plays a vital role in patient care such as it helps in:
- Improved communication
- Continuity of care
- Patient centered care
- Legal documentation
Examples of nursing care plans
The following are examples of nursing care plans of the following:
Med surg nursing care plan examples:
- Seizure nursing care plan
- Peripheral vascular disease
- Selfcare deficit
- GI bleed
Mental health nursing care plan examples:
- Dementia
- Anxiety
Meternity nursing care plan examples:
- UTI
- Infective breast feeding
Clinical skills and concepts nursing care plan examples:
- Nursing Care Plan for Ineffective Airway Clearance
- Nursing Care Plan for Activity Intolerance
Conclusion
Nursing care plans as we all know is the systematic , organized approach towards patient care. It is an important tool to guide the nurses to deliver high quality, individualized patient care. The importance of nursing care plan is it helps in communication, continuity of care and serves as legal documentation. The components of effective nursing care plan consist of assessment, diagnosis, interventions, rational, evaluation and documentation.
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