Writing
the best nursing care plan requires a step-by-step approach to doing the
essential parts of the care plan properly. This tutorial includes a final
database and a list of Nursing Care
Plans (NCP) and Nanda Nursing Assessment samples for use by Thetutorshelp.com student nurses and
professional nurses - all for free! It
includes the components, examples, goals and objectives of the care plan, and a
detailed guide to writing a nursing care plan or template for your unit.
What is a Nursing Care Plan?
Nursing
Care Planning (NCP) is a formal process that accurately identifies current
needs and potential needs or risks. Care plans provide communication between
nurses, their patients, and other health care providers to achieve health
outcomes. Without a process of planning nursing care, the quality and
consistency of patient care will be lost.
Nursing
care planning begins when the client is approved by the agency and is
constantly updated in the face of changes in the client’s condition and goal
achievement. Planning and providing personal or patient-based care is a
cornerstone of excellence in nursing practice.
Types of Nursing Care Plans
Care
plans can be informal or formal: an informal nursing care plan is a practical
strategy in the head of the nurse. A formal nursing care plan is a written by
expert or computerized guide that manages client care information. Formal care
plans are divided into standard care plans and individual care plans. Standard
care plans define nursing care
for client groups with daily needs. Individual care plans are designed to meet
the specific needs or requirements of a particular client that are not
addressed through a standard care plan.
Goals For Nursing Care Assignment
The
goals and objectives of writing a nursing care plan are as follows:
● Promote fact-based nursing
care and provide pleasant and family-friendly conditions in hospitals or health
centers.
● Support holistic care for
disease management and prevention that includes the whole person, including
physical, psychological, social and spiritual.
● Install programs such as Care Path
and CareBundle. Care pathways involve team effort to build consensus on care
standards and expected outcomes, while care bundles relate to the best practice
of caring for a specific disease.
● Identify and differentiate
between goals and expected outcomes.
● Review communications and
documentation of maintenance plans.
● Measure nursing care.
Nursing Care Planning Objectives
The
goals and importance of writing a nursing care plan are as follows:
● Explains the role of the nurse : It helps to identify the unique role of nurses
in the overall health and well-being of clients without relying entirely on
physician orders or interventions.
● It provides guidelines for individual customer care: It allows the nurse to think
critically about each client and to develop interventions that are directly
related to the individual.
● Continuity of care :
Nurses on different shifts or different destinations can use the data to
offer the same criteria and types of interventions for client care, thus
allowing clients to get the most out of treatment.
● Documentation : It should outline exactly what observations to make,
what nursing tasks to perform, and what instructions clients or family members
need. If nursing care is not properly documented in the care plan, there is no
evidence that care was provided.
● Acts as a guide for assigning specific staff to a specific
client : There
are instances when client care needs to be delegated to employees with
specialized and accurate skills.
● Acts as a guide for compensation : Medical records are used by insurance
companies to determine how much they will pay for hospital care that a consumer
receives.
● Explains customer goals : It benefits not only nurses but also clients
by involving them in their own treatment and care.
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