Nursing care plan

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A nursing care plan provides direction on the type of nursing care the individual/family/community may need. [1] The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. [2] Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the veterinary profession. [2] A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation. [2]

Contents

According to UK nurse Helen Ballantyne, care plans are a critical aspect of nursing and they are meant to allow standardised, evidence-based holistic care. [2] It is important to draw attention to the difference between care plan and care planning. [2] Care planning is related to identifying problems and coming up with solutions to reduce or remove the problems. [1] The care plan is essentially the documentation of this process. [1] It includes within it a set of actions the nurse will apply to resolve/support nursing diagnoses identified by nursing assessment. Care plans make it possible for interventions to be recorded and their effectiveness assessed. [2] Nursing care plans provide continuity of care, safety, quality care and compliance. A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid.

The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient. The TNP is the nurse's responsibility. They are the only ones who can inscribe information and re-evaluate the TNP during the course of treatment of the patient. This document is used by nurses, nursing assistant and they communicate the directives to the beneficiary attendants. The priority problems or needs are often the diagnoses of the patient and nursing problem such as wounds, dehydration, altered state of consciousness, risk of complication and much more. These diagnoses are around problems or needs that are detected by nurses and need specific interventions and evaluation follow-up. [3] The nursing directives can be addressed to nurses, nursing assistants or beneficiary attendants. Each priority problem or need must be followed by a nursing directive or an intervention. The interventions must be specific to the patient. For example, two patients with the problem 'uncooperative care' can need different directives. For one patient the directive could be: 'educate about the pathology and the effects of the drugs on the health situation'; for the other, it could be the'use a directive approach.' It depends on the nature of the problem which needs to be evaluated by a nurse. [4]

Objective

  1. To promote evidence-based nursing care and to provide comfortable and familiar conditions in hospitals or health centers. [1]
  2. To promote holistic care which means the whole person is considered including physical, psychological, social and spiritual in relation to management and prevention of the disease. [1]
  3. To support methods such as care pathways and care bundles. Care pathways involve a team effort in order to come to a consensus with regards to standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease. [1]
  4. To record care. [1]
  5. To measure care. [1]
  6. To provide treatment measure health issues or disease conditions
  7. To Ensure the Psychological support and reduce stress anxiety to the patient

History

The function of nursing care plans has changed drastically over the past several decades. In 1953, care planning was not believed to be within the nursing scope of practice. [5] In the 1970s, care planning was activity based. [5] Patients were listed according to the procedures they were having done, which determined their plan of care. [5] Care provided was passed on by word of mouth, dressing books, and work lists. [5] These forms of communication all focus on activities the nurse performed instead of focusing on the patient. [5] Today, nursing care plans focus on the individual's unique set of needs and goals. [5] Care plans are individualized to create a patient-centered approach to care. [6] Therefore, nurses must perform a physical assessment prior to planning a patient's care. [6]

Components of a care plan

A care plan includes the following components;

  1. Client assessment, medical results and diagnostic reports. This is the first step in order to be able to create a care plan. In particular client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic and environmental. Information is this area can be subjective and objective. [7]
  2. Expected patient outcomes are outlined. These may be long and short term. [7]
  3. Nursing interventions are documented in the care plan. [7]
  4. Rationale for interventions in order to be evidence based care. [7]
  5. Evaluation. This documents the outcome of nursing interventions. [7]

Computerised nursing care plans

A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. [8] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. [8] Using electronic devices when creating nursing care plans are a more accurate, accessible, easier completed and easier edited, in comparison with handwritten and preprinted care plans. [8]

See also

Related Research Articles

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A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice compared to dependent interventions driven by physician's orders. Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies the unique ways in which individuals respond to health or life processes or crises. The nursing diagnostic process is unique among others. A nursing diagnosis integrates patient involvement, when possible, throughout the process. NANDA International (NANDA-I) is body of professionals that develops, researches and refines an official taxonomy of nursing diagnosis.

<span class="mw-page-title-main">Nursing process</span>

The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. It should not be confused with nursing theories or health informatics. The diagnosis phase was added later.

Nursing theory is defined as "a creative and conscientious structuring of ideas that project a tentative, purposeful, and systematic view of phenomena". Through systematic inquiry, whether in nursing research or practice, nurses are able to develop knowledge relevant to improving the care of patients. Theory refers to "a coherent group of general propositions used as principles of explanation".

Psychiatric nursing or mental health nursing is the appointed position of a nurse that specialises in mental health, and cares for people of all ages experiencing mental illnesses or distress. These include: neurodevelopmental disorders, schizophrenia, schizoaffective disorder, mood disorders, addiction, anxiety disorders, personality disorders, eating disorders, suicidal thoughts, psychosis, paranoia, and self-harm.

Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place to be used at specific facilities and in specific circumstances.

Home health is a nursing specialty in which nurses provide multidimensional home care to patients of all ages. Home health care is a cost efficient way to deliver quality care in the convenience of the client's home. Home health nurses create care plans to achieve goals based on the client's diagnosis. These plans can include preventive, therapeutic, and rehabilitative actions. Home health nurses also supervise certified nursing assistants. The professional nursing organization for home health nurses is the Home Healthcare Nurses Association (HHNA). Home health care is intended for clients that are well enough to be discharged home, but still require skilled nursing personnel to assess, initiate and oversee nursing interventions.

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Faith Community Nursing, also known as Parish Nursing, Parrish Nursing, Congregational Nursing or Church Nursing, is a movement of over 15,000 registered nurses, primarily in the United States. There are also Parish nurses in Australia, the Bahamas, Canada, England, Ghana, India, Kenya, Korea, Madagascar, Malawi, Malaysia, New Zealand, Nigeria, Palestine, Pakistan, Scotland, Singapore, South Africa, Swaziland, Ukraine, Wales, Zambia and Zimbabwe. Faith community nursing is a practice specialty that focuses on the intentional care of the spirit, promotion of an integrative model of health and prevention and minimization of illness within the context of a community of faith. The intentional integration of the practice of faith with the practice of nursing so that people can achieve wholeness in, with, and through the population which faith community nurses serve.

Ambulatory care nursing is the nursing care of patients who receive treatment on an outpatient basis, ie they do not require admission to a hospital for an overnight stay. Ambulatory care includes those clinical, organizational and professional activities engaged in by registered nurses with and for individuals, groups, and populations who seek assistance with improving health and/or seek care for health-related problems. The American Academy of Ambulatory Care Nursing (AAACN) describes ambulatory care nursing as a comprehensive practice which is built on a broad knowledge base of nursing and health sciences, and applies clinical expertise rooted in the nursing process.

The Omaha System is a standardized health care terminology consisting of an assessment component, a care plan/services component, and an evaluation component. Approximately 22,000 health care practitioners, educators, and researchers use Omaha System to improve clinical practice, structure documentation, and analyze secondary data. Omaha System users from Canada, China, The Czech Republic, Estonia, Hong Kong, Japan, Mexico, New Zealand, The Netherlands, Turkey, the United States, and Wales, have presented at Omaha System International Conferences.

The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.

The conservation model is a model of nursing education that was created by Myra Levine in 1989.

<span class="mw-page-title-main">Holistic nursing</span> Medical care practice

Holistic nursing is a way of treating and taking care of the patient as a whole body, which involves physical, social, environmental, psychological, cultural and religious factors. There are many theories that support the importance of nurses approaching the patient holistically and education on this is there to support the goal of holistic nursing. The important skill to be used in holistic nursing would be communicating skills with patients and other practitioners. This emphasizes that patients being treated would be treated not only in their body but also their mind and spirit.. Holistic nursing is a nursing speciality concerning the integration of one's mind, body, and spirit with his or her environment. This speciality has a theoretical basis in a few grand nursing theories, most notably the science of unitary human beings, as published by Martha E. Rogers in An Introduction to the Theoretical Basis of Nursing, and the mid-range theory Empowered Holistic Nursing Education, as published by Dr. Katie Love. Holistic nursing has gained recognition by the American Nurses Association (ANA) as a nursing specialty with a defined scope of practice and standards. Holistic nursing focuses on the mind, body, and spirit working together as a whole and how spiritual awareness in nursing can help heal illness. Holistic medicine focuses on maintaining optimum well-being and preventing rather than just treating disease.

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<span class="mw-page-title-main">Cultural competence in healthcare</span> Health care services that are sensitive and responsive to the needs of diverse cultures

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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients.

Nancy Roper (1918–2004) was a British nurse theorist, lexicographer and creator with Winifred W. Logan and Alison J. Tierney of the Roper–Logan–Tierney model of nursing used widely in nurse training in the United Kingdom, USA and Europe, since mid-1970s.

References

  1. 1 2 3 4 5 6 7 8 Hooks, Robin (2016). "Developing nursing care plans". Nursing Standard. 30 (45): 64–65. doi:10.7748/ns.30.45.64.s48. PMID   27380704.
  2. 1 2 3 4 5 6 Ballantyne, Helen (2016). "Developing nursing care plans". Nursing Standard. 30 (26): 51–60. doi:10.7748/ns.30.26.51.s48. PMID   26907149.
  3. ↑ Deshaies, Carole. "Professional inspection – Documentation Standard Verification Tool – The Therapeutic Nursing Plan" (PDF). www.oiiq.org. Ordre des infirmiers et infirmières du Québec. Retrieved 17 November 2014.
  4. ↑ Leprohon, Judith. "The Therapeutic Nursing Plan – The track of clinical nursing decision" (PDF). oiiq.org/. Ordre des infirmiers et infirmières du Québec. Retrieved 17 November 2014.
  5. 1 2 3 4 5 6 Ballantyne, Helen (2016). "Developing nursing care plans". Nursing Standard. 30 (26): 51–57. doi:10.7748/ns.30.26.51.s48. PMID   26907149. ProQuest   1785225901.
  6. 1 2 Doenges, Marilynn (2014). Nursing Care Plans : Guidelines for Individualizing Client Care Across the Life Span. Philadelphia: F. A. Davis Company. ISBN   9780803640900.
  7. 1 2 3 4 5 Doenges, Marilynn; Moorehouse, Mary; Murr, Alice (2014). Nursing care plans: guidelines for individualizing client care across the life span (9th ed.). Philadelphia: F.A. Davis Company. ISBN   9780803640900. OCLC   874809931.
  8. 1 2 3 Thoroddsen, Asta; Ehnfors, Margareta; Ehrenberg, Anna (October 2011). "Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records". Computers, Informatics, Nursing. 29 (10): 599–607. doi:10.1097/NCN.0b013e3182148c31. PMID   22041791.
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