A nursing care plan (NCP) is an official procedure that includes recognizing existing needs correctly and acknowledging possible needs or risks. Care plans in a health care setting acts as a communication means between nurses, patients, and other health service providers. This is to accomplish health maintenance results. The quality of patient care will reduce if the nursing care process is not available.
Types of Nursing Care Plan
There are two types of nursing care plans; informal and formal. An informal nursing care plan is an approach of action that only exists in the nurse’s mind. Also, a formal nursing care plan on the other hand is a guide that’s either written or computerized that classifies information about the customer’s care.
Formal care plans have been broken down into a standardized care plan, and individualized care plans: Standardized care plans define the medical care for groups of customers with daily needs. On the other hand, individualized care plans on the other hand are meant for the special needs of a particular customer or demands that have not been mentioned by the standardized care plan.
Below are the aim and purpose of writing a nursing care plan:
- To encourage fact-based nursing care and to deliver good and standard conditions in health facilities.
- It promotes complete caregiving both physically and psychologically.
- Continuously analyze the communication of the nursing care plan.
Benefits of a Nursing Care Plan
- To establish the role of the nurse – It classifies different roles of nurses attending to patients.
- It helps nurses attend to customers individually.
- Patients become more involved in their own treatment too.
Steps of Writing a Nursing Care Plan
- Collection of data
When developing a nursing care plan, the first thing to do is to come up with a customer’s database. The database comprises the customer’s health information. Moreover, the nurse can identify the danger and prepare a nursing diagnosis.
- Data interpretation and coordination
Interpret and coordinate to come up with the client’s diagnosis once you have the customer’s health information.
- Develop a Nursing diagnosis
It is the best way of recognizing a customer’s particular needs. Also, nursing diagnoses are developing health complications that can be stopped by nursing involvement.
- Establishing preferences
This is the process of setting up a special order for communicating nursing diagnoses and interventions. Also, this stage involves the nurses and the customers planning on which nursing diagnosis needs attention first.
- Developing customer’s goals and preferred results
Set objectives for every priority once you have allocated precedence for nursing diagnosis. Furthermore, objectives express what the nurse would like to attain by executing nursing involvement, and they are obtained from the customer’s nursing diagnosis.
Goals are either long term or short term. Goals are usually short-term in a critical care environment, and this is because mostly, the nurses are spending more time on the customer’s emergency needs. Long-term objectives are normally used for customers with incurable health problems, or those under home care, and assisted living facilities.
- Long term goal – It shows an aim that is supposed to be finished within a long period of time.
- Short term goal – It is a statement differentiating a change in behavior that can be finished within a short period of time.
- Choosing nursing interventions
Nursing interventions are steps that a nurse undertakes to attain a customer’s goals. Interventions selected should concentrate on removing or lowering the causes of the nursing diagnosis. Interventions should concentrate on lowering the customer’s risk factors. Nursing interventions therefore are recognized and written down throughout the organization stage of the nursing process. Nevertheless, they are actually carried out during the execution stage.
Types of Nursing Interventions
Independent nursing interventions
These are tasks that nurses have been licensed to perform depending on their skills.
Dependent nursing interventions
These are tasks performed by nurses but under a doctor’s supervision. So this usually happens when physicians direct nurses to administer certain medication, therapy, or exercise.
These are tasks that nurses perform together with other health care providers such as doctors, nutritionists, or social workers.
Evaluation is an essential feature of the nursing process because the conclusions that will be drawn from this stage will dictate if the nursing intervention will be stopped, continued, or changed.
- Writing it on paper
The customer’s nursing care plan is recorded as per the hospital’s code. It becomes part of the customer’s permanent medical history which may be analyzed by the upcoming nurse.
Nurses are willing to follow care plan demands if they don’t have to go and look for a computer first. If there’s a possibility that they can access the care plan from mobile phones, then they can analyze and update care plans while attending to the patient. They can as well check them regularly to guide the patient. Follow the above steps and you will be able to write an excellent nursing care plan. If you still have any doubt, visit collegenursingtutors.com for more help.