A nursing care plan outlines the nursing care to be provided to a patient. It is a set of actions the nurse will implement to resolve nursing problems identified by assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.
Characteristics of the nursing care plan
- It focuses on actions which are designed to solve or minimize the existing problem.
- It is a product of a deliberate systematic process.
- It relates to the future.
- It is based upon identifiable health and nursing problems.
- Its focus is holistic.
Elements of the plan
In the USA, the nursing care plan consists of a NANDA nursing diagnosis with related factors and subjective and objective data that support the diagnosis, nursing outcome classifications with specified outcomes (or goals) to be achieved including deadlines, and nursing intervention classifications with specified interventions.
The nursing process
Care plans are formed using the nursing process. First the nurse collects subjective data and objective data, then organizes the data into a systematic pattern, such as Marjory Gordon's functional health patterns. This step helps identify the areas in which the client needs nursing care. Based on this, the nurse makes a nursing diagnosis. As mentioned above, the full nursing diagnosis also includes the relating factors and the evidence that supports the diagnosis. For example, a nurse may give the following diagnosis to a patient with pneumonia that has difficulty breathing: Ineffective Airway Clearance related to tracheobronchial infection (pneumonia) and excess thick secretions as evidenced by abnormal breath sounds; crackles, wheezes; change in rate and depth of respiration; and effective cough with sputum.
After determining the nursing diagnosis, the nurse must state the expected outcomes, or goals. A common method of formulating the expected outcomes is to reverse the nursing diagnosis, stating what evidence should be present in the absence of the problem. The expected outcomes must also contain a goal date. Following the example above, the expected out come would be: Effective airway clearance as evidenced by normal breath sounds; no crackles or wheezes; respiration rate 14-18/min; and no cough by 01/01/01.
After the goal is set, the nursing interventions must be established. This is the plan of nursing care to be followed to assist the client in recovery. The interventions must be specific, noting how often it is to be performed, so that any nurse or appropriate faculty can read and understand the care plan easily and follow the directions exactly. An example for the patient above would be: Instruct and assist client to TCDB (turn, cough, deep breathe) to assist in loosening and expectoration of mucous every 2 hours.
The evaluation is made on the goal date set. It is stated whether or not the client has met the goal, the evidence of whether or not the goal was met, and if the care plan is to be continued, discontinued or modified. If the care plan is problem-based and the client has recovered, the plan would be discontinued. If the client has not recovered, or if the care plan was written for a chronic illness or ongoing problem, it may be continued. If certain interventions are not helping or other interventions are to be added, the care plan is modified and continued.
There are also care plans written for "at risk" problems, as well as "wellness" care plans. These follow a similar format, only designed to prevent problems from happening and continue or promote healthy behavior.
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