The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds.
Care plan provides directions for individualized care of the customer. Each customer is admitted in the hospital for the treatment requires unique treatment. Two customers having same disease conditions but showing different symptoms which requires to treat different way, that nurse has to identify with thinking critically and logically. It helps customer to get prompt treatment and it also helps to increase customer satisfaction.
- Care plans help to documentation.
- The care plan should specifically outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require.
- They serve as a guide for assigning staff to care for the client.
- There may be aspects of the patient’s care that need to be assigned to team members with specific skills.
A plan, based on a nursing assessment and a nursing diagnosis, carried out by a nurse. It has four essential components:
- Identification of the nursing care problems or nursing diagnoses and statement of the nursing approach to solve those problems;
- Statement of the expected benefit to the patient;
- Statement of the specific actions by the nurse that reflect the nursing approach and achieve the goals specified;
- Evaluation of the patient’s response to nursing care and readjustment of that care as required.
The nursing care plan is begun when the patient is admitted to the health service, and, after the initial nursing assessment, a diagnosis is formulated and nursing orders are developed. The goal of the process is to ensure that nursing care is consistent with the patient’s needs and progress toward self-care. A written nursing care plan should be a part of every patient’s day to day activity.
The exact format for a nursing care plan varies slightly from place to place. They are generally organized by four categories:
- Nursing diagnoses (problems & need identified);
- Goals and outcome criteria;
- Nursing orders (Interventions);
Nursing diagnoses are clinical judgments about actual or potential individual, family or community experiences or responses to health problems or life processes.
Nursing diagnoses differ from medical diagnoses. A medical diagnosis — which refers to a disease process — is made by a physician and will be a condition that only a doctor can treat. In contrast, a nursing diagnosis describes a client’s physical, socio-cultural, psychological and spiritual response to an illness or potential health problem. For as long as a disease is present, the medical diagnosis never changes, but a nursing diagnosis evolves as the client’s responses change.
Interventions or nursing orders which we can be wrote in the form of nursing treatment. suppose customer complaints or informs related to fever, nurse has to check temperature, informs doctor, as per doctor order she may give medication or tepid sponging to that customer, after 0ne hour again she has to check the temperature and writes the actual condition of the customer whether his temperature reduce or require another treatment.
Evaluation, the client’s health care professionals will determine the progress towards the goal achievement and the effectiveness of the nursing care plan. The evaluation is extremely important because it determines if the nursing interventions should be terminated, continued or changed.
Care plans teach nursing staffs how to think critically, how to care for patients on a more personal level, not as a disease or diagnosis. They help them how to prioritize care and interventions.
- Its’ focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.
- It is based upon identifiable nursing diagnoses (actual, risk or health promotion) – clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.
- It focuses on client-specific nursing outcomes that are realistic for the care recipient
- It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.
- It is a product of a deliberate systematic process.
- It relates to the future.