What Is a Performance Improvement Plan?

A nursing care plan is a formal document that includes all of the patient’s health information and identifying their current needs and anticipating the potential risks. It is a means among nurses to communicate with fellow nurses, patients, and other healthcare providers to achieve care outcomes. It also ensures that the quality and consistency of care in patients remains.

Having a nursing care plan will ensure that everyone involved in patient care is on the same page, thus minimizing errors. It’s a document that healthcare providers use as a reference since all patient information is on it such as diagnoses, goals of treatment, and specific nursing orders (like what needs to be observed or actions to perform) as well as plans for evaluation. As a patient’s condition improves or changes, the information on the care plan is also updated with the new information as it presents itself.

Must-Have Elements in a Nursing Care Plan

Depending on the workplace, nursing care plans may vary. But in most cases, it includes all the elements and contains the same information such as the diagnoses, goals or anticipated outcomes, nursing orders, and evaluation.

Diagnoses. According to the North American Nursing Diagnosis Association – International (NANDA-I), nursing diagnoses are a compilation of a list of health problems or medical conditions of the patient. It is used to determine the appropriate care that the patient should receive. A diagnosis is made after a thorough and holistic patient assessment. Outcomes/Goals. Goals focus on problem prevention, resolution, and rehabilitation of the patient. This can either be long-term or short-term, depending on the patient’s needs. Short-term goals are usually behavior modification that can be completed immediately–usually done in a few hours or days. Long-term goals, on the other hand, are behavior modifications that usually take weeks or months to complete.Nursing Orders and Interventions. Nursing orders also called interventions, are measurable, patient-centered, and have parameters that correlate to the desired outcomes. Usually, these interventions are created after the goals have been set. Nurses and other healthcare professionals often refer to the NANDA nursing diagnosis list to determine how to care for patients based on their diagnosis.Evaluation. The evaluation section of the care plan is an important element. It usually takes place after the plan has been implemented and nursing orders and interventions were provided to the patient. As treatment continues, evaluation and re-evaluation of patient condition are done to revise or update the plan when necessary based on outcomes.

How to Create a Nursing Care Plan

The best nursing care plan requires a step-by-step approach and goes beyond the nursing diagnosis list. In creating a care plan, it must have all relevant information about the patient. Apart from knowing and understanding patient conditions, diagnoses, and their definitions, healthcare providers are required to have critical thinking. Follow these steps to develop a care plan for your patient.

Step 1: Data Collection and Assessment

The first step in nursing care plan creation is the data collection and assessment. To begin, one should ask what type of data is collected to identify the patient’s current medical condition and health problems. The American Nursing Association (ANA) states that the assessment process must include different factors such as physical, psychological, sociocultural, spiritual, economic data, and lifestyle. The most common approach to this is through an interview and physical examinations. 

It’s also important that nurses review the patient’s medical history, diagnosis, and lab test results, as well as medications for any diseases or mental health issues. Through this step, nurses can identify the risk factors and pertinent information which is critical so that they can make a diagnosis.

Step 2: Data Analyses and Diagnoses

After collecting patient data and assessment has been done, a diagnosis has to be made. A good care plan should define a diagnosis after analyzing and taking into consideration all gathered information about the patient. Usually, analysis of data involves comparison of patient data versus standards, clustering of cues, and identifying gaps and inconsistencies. 

One of the most cited references is the NANDA-I nursing care plan diagnoses as a way to identify, focus and deal with specific patient needs and how to respond to actual high-risk health problems. Having a uniform standard of diagnoses eliminates confusion moving forward in the treatment and care plan of the patient.

Step 3: Data Collection and Assessment

Once diagnoses have been made, prioritization of findings should be established to determine the sequence of treatment and procedure to address patient needs. In this step, proper diagnoses are ranked based on their impact on patient health–life-threatening health problems are given high priority, and others determined to be either medium or low-risk are dealt with after. The patient’s values, beliefs, their own priorities, as well as the availability of resources, and urgency of other factors must also be considered during prioritization. For example, if a diabetic patient recently had a stroke and with existing comorbidities, healthcare providers should come up with one holistic care plan for the patient that addresses the most pressing health issue first. 

After which, goals or desired outcomes are set for each priority. This means writing down what healthcare professionals hope to achieve with the interventions implemented to address patient’s concerns and nursing diagnoses. Having goals also provide direction in the intervention and treatment planning as well as serve as criteria during evaluation of the patient’s health progress.

Step 4: Nursing Intervention and Rationale of the Treatment

Nursing interventions are the nursing orders which include the activities and actions that nurses have to perform to achieve the set goals for the patient. In other words, these are the treatments that will be given or provided to the patient to address their health problems. It includes a checklist of the activities on how nurses will take care of the patient.

As an evidence-based plan, documentation of treatment implementation is required. That’s why it is important that nurses monitor the patient’s health closely and document it in their health record. This part of the plan is also dynamic and will be updated as the patient’s health conditions change or improve and will be the basis if the patient is okay to be discharged.

Step 5: Evaluation of the Executed Care Plan

Aside from implementing the care plan all throughout the patient’s hospitalization, their health status should be monitored and evaluated based on the goals set. Results of the evaluation will determine the effectiveness of the intervention and care being provided to the patient and if the NANDA diagnosis needs to be modified or changed, or if the treatment plan has been completed and the patient is ready to go home. 

Importance of Nurse Care Plans

Writing a nursing care plan isn’t just for compliance. It is an important document for patient care and is used by many healthcare professionals involved in the treatment of patient’s health issues. The following are the purposes and importance of a nurse care plan:

Different types of Care Plans

There are a vast variety of diseases out there that people may or may not contract in their lifetime. But whatever that may be, there is a care plan for that. Various diseases and health conditions are grouped together and are segmented per category such as:

Is there a specific care plan format to follow?

There is no one particular format to follow when it comes to care plans. As long as it contains all of the four components such as the problem as defined in the nursing diagnosis, goals set or the expected and desired outcomes, nursing interventions agreed upon by all healthcare providers involved, and evaluation of the success of the treatment or interventions.

What are other considerations in writing a care plan?

Aside from the main elements of a care plan and physician’s orders, other considerations in writing one include: Patient’s choice and preferences and their willingness to participate and change Include small manageable steps that the patient can easily carryout Establish who is responsible to the patient’s care plan and use layman’s language Set realistic goals and objectives to measure success to keep patients motivated

Are nursing interventions the same as physician interventions?

No. They are not the same. Nursing interventions do not necessarily require doctor’s orders such as reposition the patient or teaching them breathing techniques after surgery. Physician interventions, on the other hand, are carried out by the nurses such as medication administration and monitoring of certain patient behavior or output like urine and stool.

Can nurses question the physician’s intervention orders?

Yes. Nurses are liable for all interventions that they carry out so they should ask and question any interventions that they think are inappropriate or will not work considering the patient’s health conditions.

What are some examples of nursing care plans?

Each diagnosis has a standardized care plan but it can be adjusted based on the patient’s needs and current medical condition. There are care plans specifically for pain, cardiovascular and respiratory diseases, and cancer. Patient’s lifestyles, beliefs, and values are also taken into consideration, so care plans per patient vary.

As a final thought, a nursing care plan is an important document that allows healthcare professionals to collaborate and work together in harmony. Continuity of care is ensured and patients are provided with the best possible care that they deserve. It also serves as a database of all of the patient’s information throughout their stay at the hospital. It is patient-centered care that encompasses the promotion of health, treatment, and care of the diseases as well as its prevention and caring for the ill, disabled, and those who are dying.