Nursing care plans are part of the nursing process and assist the nurse in developing measurable goals and outcomes for patient care. The nursing care plan includes the nurse's assessment of the patient, a nursing diagnosis, specific nursing actions to help the patient achieve outcomes and goals, and a re-assessment of the patient to determine if the patient is achieving those goals. A nursing care plan is unique to each patient and should be holistic, meaning it should account for the entire patient and not merely the disease or diagnosis.
Instructions
1. Conduct a complete nursing assessment of the patient. During the nursing admission process, the patient will outline desired goals and outcomes. Assess the patient's learning needs and how willing the patient is to learn. Patient education is part of an individualized care plan and is geared toward the unique learning needs of each patient. For example, a newly diagnosed diabetic patient may need education regarding medication, foot care and eye care; that patient also may need other or different types of medication. The nurse assesses each patient individually to determine precise needs.
2. Formulate a list of goals as expressed by the patient in his/her own words. A patient admitted for knee surgery may state a goal as, "I want to walk as quickly as possible after surgery." The nurse listens to the patient and records his/her words, verbatim what the patient says. A patient's stated goals may be different from what the nurse observes or feels the patient should be doing. Nursing interventions are tailored to the specific need of the patient to achieve that goal.
3. Develop nursing interventions that will achieve the patient's stated goal. The nurse uses the critical-thinking process to prioritize the patient's goals and to assist the patient in achieving those goals. The care plan is dynamic and is revised according to the patient's needs. Re-assessment of the patient and revision of the care plan is an ongoing process. The initial planned intervention may not meet the needs of the patient, requiring revision of the care plan.
4. Use evidence-based practices to formulate an individualized care plan. The nurse recognizes that each patient is unique and that the outcomes are based on the goals that the patient presents. Best practices and outcomes are based on current knowledge and understanding of existing practices that can be tailored to the patient. Evaluate the effectiveness of the care plan with the patient to ensure that outcomes are achieved and patient satisfaction is maintained. The care plan can be updated as often as there is a change in patient condition or as the patient has different goals and expresses those. All aspects of the care plan---including pain management, skin care and other assessments---are vital and dynamic components of the plan. The care plan is shared with the nursing team and is often part of the shift change report, which updates the nursing team on the patient. All members of the nursing team have input into the care plan, as they have different perspectives of the patient and the patient's progress.
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