Nursing Care Plans Ultimate Guide

What is Nursing Care Plan

The NCP is a formal approach that precisely identifies current patient requirements and possible risks. Care plans serve as a mode of exchanging information among patients, nurses, and healthcare providers to attain care plan objectives. Furthermore, the care plan process helps uphold the quality and consistency of patient care.

The NCP process commences when a client is accepted to healthcare and is regularly updated when their body responds to medication and evaluation of the achieved goals. A distinction in nursing practice is based on planning and delivering patient-centered or personalized care.

Categories of Nursing Care Plans

NCP could be either formal or informal. A formal NCP is a structured guide that organizes patient care information. In contrast, informal NCP is a less structured approach to actions existing in the nurse’s mind.

Personalized care plans and standardized care plans are subdivisions of formal care plans. A customized care plan aims to achieve particular patient needs or needs that standardized care plans do not address. Standardized care plans provide nurses with specific nursing care for patients with daily needs.

Standardized Care Plans

Standardized care plans are guides pre-developed by healthcare agencies and nursing staff to enhance consistent care to patients with particular conditions. These care plans are meant to enhance the effective utilization of time and ensure acceptable minimal criteria are achieved by eliminating the creation of common repeated activities for most patients in a nursing care unit. Standardized care plans are not patient-centered and are a good starting point for developing a personalized care plan.

Personalized Care Plans

A personalized care plan entails directing the standardized care plan toward an individual specific needs and utilizing specific approaches that seem adequate to a particular patient. The techniques used in this care plan allows more holistic and individualized care suited to the patient’s unique goals, strength, and needs

Besides, personalized care plans play a significant role in enhancing the satisfaction of the patient. Tailoring care towards the specific patient needs makes them feel valued and heard, leading to high satisfaction with the provided care. A personalized care plan is essential in the modern healthcare environment, where one of the quality measures is patient satisfaction.

Objectives of writing a Nursing Care Plan

The objectives and goals of developing NCP include:

Measure nursing care.
Distinguish objectives and desired results.
Review documentation and communication of the NCP.
Develop programs like care bundles and care pathways. The care pathway determines the expected Outcome and standards of care by involving a team of efforts. On the other hand, care bundles are associated with acceptable nursing care practices for a specific condition.
Assist holistic care, including social, spiritual, physical, and psychological, with prevention and management of the disease.
Encourage evidence-based care and provide familiar and pleasant hospital conditions.

Objectives of Nursing Care Plan

The importance and objectives of developing NCP include the following:

Continuity of care. The data in the nursing care plan document can help the nurses from various shifts to provide similar interventions and quality care to patients, allowing patients to get the best from the treatment.
Coordinate care. Helps eliminate care gaps by ensuring the healthcare teams know the patient’s care needs and interventions to be taken.
Offer direction for personalized care of the patient. It aids healthcare teams with a roadmap toward patient care and allows nurses to think critically in creating customized interventions.
Monitor progress. Helps in tracking the client’s progress and make changes to the care plan according to the health status and goals of the patient.
A care plan should clearly outline the nursing interventions, observations to make, and type of instruction to give the patient or family.
Acts as guidance for assigning a patient to specific staff. Some patients’ care needs a nurse with special and unique skills.
Reimbursement guide. The medical records are vital for insurance companies to determine what to pay regarding hospital care provided.
Define the role of the nurse. A nursing care plan aids in the identification of the independent and unique functions of the nurses in responding to patients’ overall well-being in the absence of doctors’ interventions.
Defines patient’s goals. It is an essential document for nurses and patients because it includes them in their care and treatment

Components of Nursing Care Plan

Nursing diagnosis. It is based on assessment data gathered about the patient’s health status. It describes the health concerns of the patient.
Nursing interventions. It includes specific actions to respond to nursing diagnoses and attain desired goals. Nursing interventions should be evidence-based and follow appropriate nursing practices.
Patient health assessment. Diagnostic reports and medical results are the initial steps in care plan development. The patient assessment associated with the following abilities and areas like sexual, cultural, functional, environmental, economic, physical, emotional, and age-related could be objective and subjective.
This involves the strategies for evaluating and monitoring a client’s progress and making significant changes to the care plan based on their health status and goal change.
The nursing inventions specified are explained using evidence-based.
Expected patient Outcome. The specific goals are to be attained via nursing interventions. These goals could either be long-term or short-term.

Care Plans Formats

The care plan forms are primarily structured into four columns: Nursing diagnosis, Desired goals and Outcome, Nursing initiatives, and Evaluation. However, some organizations use a three-column design and combine Evaluation and goals in one column; others add an assessment column to have a five-column plan.

Three-column Format

This type of NCP has three columns. Column 1: Nursing diagnosis. Column 2: Outcome and Evaluation. Column 3: Interventions.

Three-Column Nursing Care Plan Format

Nursing Diagnosis

Outcome and Evaluation

Interventions

Activity intolerance RT exhaustion associated with average sleep interruption due to discomfort, dyspnea, and excess coughing.

-During activity no reports of dyspnea.

-Essential symptoms within normal range.

1.During the acute phase, reduce the number of visits and provide a quiet environment.

2.Pace activity for clients with minimal activity.

3.Help the patient to stay in a comfortable position for sleep and rest

Four-Column Care Plan Format

This type of NCP has four columns, Nursing diagnosis, Expected goals and Outcome, Nursing interventions, and Evaluation.

Four-Column Care Plan Format

Nursing Diagnosis

Expected goals and Outcome

Nursing interventions

Evaluation

Compromised respiratory tract clearance RT, inflammation of bronchial and tracheal, formation of edema, high sputum formation AEB coughing, purulent sputum, dyspnea.

After nursing interventions of eight hours, the patient is expected to maintain/display patent respiratory tract with the sound of breath clearing: absence of cyanosis, dyspnea as shown by keeping patent respiratory tract and effectively clearing secretions.

1. Examine the rhythm, rate, chest movement, respiration depth, and utilization of accessory muscles.

2. Raise the patient’s head and change position regularly.

3. Suction as prescribed: regular coughing, unexpected breath sounds, desaturation associated with respiratory tract secretion.

After nursing interventions of eight hours, the patient was able to maintain/display a patent respiratory tract with the sound of breath clearing AEB, absence of cyanosis, and dyspnea.

Generating a Nursing Care Plan

Developing NCP for a patient involves the following steps:

Step 1: Collection of Data or Evaluation

The initial phase in writing NCP is developing a patient database by assessing the patient while collecting data. In this case, do a physical exam, review medical records, health history, interview, and diagnosis study. This step could help the nurse to identify risk factors and other related characteristics essential in formulating a diagnosis. Some nursing schools and healthcare agencies have unique assessment formats they use.

Step 2: Data Analysis and Organization

The data gathered in step 1 about the patient’s health is clustered, organized, and analyzed to develop a nursing diagnosis, desired results, and priorities.

Step 3: Nursing Diagnosis Formulation

NANDA (North American Nursing Diagnosis Association) helps standardize nursing language and provides a universal strategy for focusing on, identifying, and dealing with particular patient requirements and responding to actual or potential problems. Nursing diagnosis refers to potential or existing issues that an independent nursing intervention can prevent or resolve.

Step 4: Setting Priorities

This step involves developing preferences for actions to take on various diagnoses and interventions. The nurse and patient plan on the agency of the diagnosis. The diagnosis can be grouped and ranked according to an agency, such as high, medium, and low. High-risk problems should be a priority.

Abraham Maslow, in 1943 developed a hierarchy of needs that aids in prioritizing and planning care based on the patient-centric Outcome. According to Abrahams Maslow, basic physiological goals/needs should be prioritized before high goals/needs can be attained. The safety and physiological needs of the patient are the foundation of the execution of nursing care and measures. Thus, in Maslow’s pyramid, they are at the base, providing the basis for emotional and physical health.

Maslow’s Classification of Needs

Physiological Needs: Elimination, breathing, airway, nutrition, circulation, sex, exercise, sleep, and shelter.
Safety and Security: preventing injury, creating trust and safety, and patient learning.
Love and Belonging: promote positive relationships, techniques to evade social isolation, sexual intimacy, therapeutic communication, and use active listening strategies.
Self-Esteem: personal achievement, accepting unique physical appearance, and acceptance at work and in the community.
Self-Actualization: spiritual growth, empowering environment, utilizing maximum potential and ability to accommodate the point of views of others.

Henderson’s fourteen Components as applied to Maslow’s Hierarchy of Needs

Step 5: Develop Patient Goals and Desired Outcomes

The patient and the nurse set the desired outcomes/goals of the nursing diagnosis prioritized in step 5. Goals describe the nurse’s expectations after executing the initiatives obtained from patient diagnosis. Goals are essential in offering directions for planning initiatives, enabling the patient and nurse to rule out resolved problems, helping evaluate patient progress, and encouraging the nurse and client by offering a sense of progress.

Examples of goals and the desired Outcome:

Patient with airway problems due to Pneumonia

After nursing interventions of eight hours, the patient is expected to display patent respiratory tract clearance indicated by the absence of cyanosis, dyspnea, and a respiratory rate of between 12 to 16 breaths per minute.

Patients with acute pain

The patient will show the use of proper diversional relaxation skills and activities and indicate pain at less than 3 to 4 on a 0 to 10 scale.

· Long-term and Short-term goals

The expected outcomes and goals should be patient-centered and measurable. They are created based on resolution, rehabilitation, and prevention. The goal in acute care is short-term because most of the time is spent on the patient’s requirements. Long-term plans are for patients with chronic medical needs or receiving home-based care or extended-care clinics.

· Component of Goals and Desired Outcomes

The outcomes/goals statement has four components: a verb, a subject, a criterion of preferred performance, and modifiers or conditions.

Examples of components of goals and desired Outcome

Subject

Verb

Modifiers or conditions

Criterion

Patient

Will walk

Unassisted with crutches

By discharge

Verb: is the action the patient is supposed to take, for instance, what the patient is expected to do, experience or learn.
Subject: the subject is a patient/client, patient attributes, or part. In most cases, the patient/subject is not included when generating goals since it is presumed to be the patient.
Modifiers or conditions: modifiers are words like when, where, how, and what that are included in the verb to clarify under what circumstances the behavior should be executed.
The criterion of expected preferences: indicates the requirements to evaluate a performance or levels at which a patient is expected to perform a specific behavior.

The following are essential tips when developing goals and desired outcomes:

Goals and outcomes are based on patient response. Focus each plan on the client’s response and behavior.
The goals should not focus on the nurses’ accomplishments but on what the patient is expected to do.
Desired results must be realistic for patient capabilities, resources, limitations, and time frame.
Ensure the goals are aligned with other professional therapies.
Every goal should be derived from one nursing diagnosis.
Ensure the patient values the goals to enhance cooperation.

Step 6: Selecting Nursing Interventions

Nursing inventions refer to actions performed by nurses to realize patient goals. Preferred measures should focus on minimizing the origin of the nursing diagnosis. The nursing measures should focus on reducing patients’ risk factors. The nursing initiatives are determined and noted in the planning phase; however, actual performance occurs in the execution phase.

· Types of Nursing interventions

Nursing interventions are grouped into three; collaborative, independent, or dependent.

Collaborative: Actions carried out by nurses in conjunction with other healthcare workers like social workers, physicians, therapists, and dietitians. Healthcare professionals are involved in developing actions and giving their professional points of view.
Independent: Practices that nurses have a license to perform independently based on their skills and sound judgment, such as emotional support, teaching, making referrals, providing comfort, and physical care.
Dependent: interventions carried out under the supervision or instructions of the physicians. They include orders to give a patient-specific medication, diagnostic tests, intravenous therapy, diet, treatment, rest, or activity. Providing assessment-based explanations when carrying out medical orders is part of a dependent nursing initiative.

Nursing initiatives should be:

Realistic and attainable with the available resources and within the time frame.
Appropriate and safe for patient health, condition, and age.
Aligned other prescribed therapies
Derived from nursing experience and skills.
Aligned with patient culture, beliefs, and values.

Tips to follow when developing nursing interventions:

Correctly write the date and signature. The date when the plan was created helps evaluate, plan, and review. The signature is a demonstration of the nurse’s accountability.
Specific nursing intervention and writing starting with an action verb.
Uses accepted abbreviations by the facility.

Step 7: Providing Rationale

Rationale (scientific explanations) explains why a specific measure was used in NCP. The regular care plans do not have a rationales column. Rationale columns are usually included to help nursing students relate psychological and pathophysiological principles with specific nursing initiatives.

Examples of nursing interventions and rationale

Nursing intervention

Rationale

Examine respiratory: rate, note quality, rhythm, depth, position preferred for easy breathing, and utilization of accessory muscles.

Respiratory diseases depend on the lung’s level of involvement and underlying health conditions. Patients adapt to their breathing patterns to enhance effective breathing.

Raise the head, encourage a regular change of position, effective coughing.

The strategies enhance maximum chest expansion, improve ventilation and mobilize secretions.

Step 8: Evaluation

Evaluation is an ongoing, purposeful, and planned activity where the patient’s progress towards set goals is assessed, and the productivity of the NCP. This is a vital aspect of the nursing process because its conclusions determine whether the current nursing measures be removed, adjusted, or continued.

Step 9: Writing it Down

The patient’s care plan is written in line with the facility guidelines and is, therefore, part of the patient’s permanent health record, which oncoming nurses can review. There are different care plan formats for various nursing programs. In most cases, a five-column form is used. This is to help the nursing students systematically learn via associated steps in the nursing process.