Writing a nursing care plan: things that matter
Let’s start with the basics: what is actually a nursing care plan? This is a process of identifying and writing down the main current and potential patient needs and risks and also describes ways of communication among medical staff. Care plans help nurses to plan and achieve healthcare outcomes providing quality of service and proper customer care. Each patient is treated individually which is the perfect basis for the nursing practice.
Goals and main components
There are two types of NCP: formal (a detailed instruction that helps to organize the information about the patient) and informal (a strategy that nurses have in mind). Formal can be also divided into standard (clients with everyday needs) and individual (patients with unique needs) plans. The main goals of each plan are to:
- promote nursing care and provide good conditions in centers and hospitals;
- create programs that involve a team effort for a particular disease;
- identify and describe the main goals, review documentation and calculate the expected outcome;
- support and take care of the patients.
Writing a nursing care plan has the following advantages: it defines the role of the nurse in the healthcare and customers well-being, provides detailed individual instructions of taking care of the patient, makes it convenient for nurses from different shifts to exchange information and serves as a guide for specific staff and specific clients. The main components of NCP are client health assessment, nursing interventions, expected outcomes, and evaluation.
How to write a NCP
Here is a quick guide that can help you write your own nursing plan:
- Collect the data. First of all, you need to create your own database of clients you are working with (include their health history, medical records etc);
- Analyze the info. Now when you have all the information about your patients, study it carefully, formulate the diagnosis and set priorities (urgency and available resources);
- Establish client goals and expected outcomes. You should describe what you want to achieve, plan interventions, evaluate the progress, identify the problems that need to be resolved and motivate your clients;
- Select the interventions. Here you should mention activities or actions you will take to achieve set goals focusing on reducing risk. Provide a rationale (the reasons why the intervention was chosen);
- Evaluate. Examine what you planned, the effectiveness of the methods and actions taken. Put in on paper according to the policy of your hospital format and policy.
Different hospitals have different nursing plans, but we described the basic elements that should be included.