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Published: October 18, 2018



Trainee nurses probably have a no more hated class assignment than the ‘nursing care plan’. They’re assigned, for intensive care patients, mental health, even for community care.

The Purpose of the Written Care Plan

Care plans provide direction for individual care of the patient. A care plan flows from each patient’s unique list of diagnoses and should be organized to address the specific needs.
The care plan is a means of communicating and organizing the actions of a constantly changing nursing or care staff.
Care plans help teach documentation and recording. The care plan should specifically outline which observations to make, medication to deliver, 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 or family members.
The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client. If nursing care is not documented precisely in the care plan, there is no proof the care was provided. Insurers will not pay for what is not documented.
The purpose of students creating care plans is to assist them in pulling information from many different scientific disciplines as they learn to think critically and use the nursing process to problem solve.

Care Plan Formats

The exact format for a nursing care plan varies slightly from place to place. They are generally organized by four categories: diagnosis or problem list; goals and outcome criteria; tasks; and evaluation.

Nursing diagnoses also provide a standard nomenclature for use in the Electronic Health Record (EHR) in the UK or the Electronic Medical Record (EMR) in the US, allowing for clear communication among care team members and the collection of data for continuous improvement in patient care.

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, sociocultural, psychologic 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 and care evolves as the client’s responses change.

The goal as established in a nursing care plan — in terms of observable client responses — is what the nurse hopes to achieve. It is a desired outcome or improvement in the client’s condition. For EG, a goal might be a patient’s nutritional status will improve, while the outcome would be the patient will gain five pounds by a certain date.

Nursing orders are instructions for the specific activities that will perform to help the patient achieve the health care goal. How detailed the order is depends on the health personnel who will carry out the order. Nursing orders will all contain:

The date
An action verb like “monitor,” “instruct,” “palpate,” or something equally descriptive
A content area that is the where and the what of the order, for example, placing a “spiral bandage on the left leg from ankle to just below the knee”
A time element will define how long or how often the nursing action will occur
The signature of the prescribing nurse, since orders are legal documents.
Finally, in the 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.

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