Outstanding Care Plan Examples
When you are a nursing student, there is nothing more difficult and irritating than writing nursing care plans. You can’t imagine a thing more tiring and boring than care plan writing. Every time you enter a new course or discipline, care plan assignments are already there. You know that you will have sleepless nights and tired eyes before you are able to craft something really decent.
Care Plan Examples – Purpose and Intent
- The purpose of any care plan is to create a framework for delivering individualized patient care. It usually incorporates the fullest information about the patient’s health and provides recommendations to help the patient address his or her health concerns.
- Care plans are developed to ensure that the provision of care to patients is smooth and continuous. It articulates and specifies what the patient needs and how these needs can be adequately satisfied. For example, when a new nurse comes at the beginning of the shift, he or she can use the plan of care to continue the treatment course developed for each patient.
- Documentation must be proper and accurate. This is one of the keys to delivering high-quality nursing care. A nursing care plan documents the most detailed instructions for nurses and patients, thus reducing the risks of medical errors.
- Nursing care plans facilitate effective on-site decisions. For example, they allow nurses to make staffing decisions. They can also be helpful in making patient referrals.
- Ultimately, it is with the help of nursing care plans that healthcare facilities manage their reimbursement processes and issues. These plans are often the main documents used by Medicaid and Medicare. Insurance companies also use patients’ records and care plans to make reimbursement decisions. If nurses fail to provide accurate documentation, they will not receive the amount of reimbursement required to cover their clinical expenses.
This being said, when a nursing student receives a task to develop a nursing care plan, its purpose is to boost creativity and critical thinking while allowing the student to document each step and action during his or her encounter with the patient.
Formatting Nursing Care Plans
As for formatting, the exact requirements may vary from one clinical institution to another. However, most care plans will be divided into four sections: nursing diagnosis; desired treatment outcomes; treatment options; and evaluation or follow-up. NANDA-I is one of the basic formats used for making nursing diagnoses. It is also used in nursing care plans. Nurses use NANDA-I to formulate their observations of the patient, his or her family, and other issues related to the patient’s health. A proper nursing diagnosis is the starting point in developing a nursing care plan. It sets the stage for outlining the best evidence-based treatment recommendations for the patient.
Nursing diagnoses are standardized options that can and, actually, must be included in patients’ Electronic Medical Records. The use of standardized nursing languages facilitates communication within and across hospital facilities.
A nursing diagnosis is not the same as a medical diagnosis. A medical diagnosis is made by a physician, based on a thorough analysis of patient’s symptoms. Only a physician is in a position to treat a medical condition. In contrast, a nursing diagnosis is a more holistic category. Apart from the patient’s physical symptoms, it also incorporates cultural, socioeconomic, psychological, emotional and spiritual variables. A thorough analysis of these variables helps nurses to determine the right course of clinical action and work in the patient’s best interests.
Once a nursing diagnosis is made, the nurse should set a clear and measurable goal for the nursing care plan. For instance, it is to keep the patient’s blood glucose levels within the normal range. It may also include more general goals such as improve the patient’s wellbeing or redesign the patient’s lifestyle. For example, the nurse may include recommendations to increase the amount of time the patient spends outdoors.
Then come nursing orders that are done to meet the goals and objectives set in the nursing care plan. It is a set of actions, recommendations and decisions that should move the patient closer to his or her health goals. Each order will contain the following information:
- A verb that defines the meaning of the action to be taken
- The details or specifics of the order
- Duration of the recommendation (e.g., taking pills for 1 month)
- Nurse’s signature
Signature is a critical component of each and every nursing order, because these orders are legal documents and should be treated as such.
Ultimately, a nursing care plan should include recommendations for evaluation and follow-up. It is a description of the actions that the nurse will undertake to evaluate changes in the patient’s health and wellness. These activities are vital for the patient because they can help the nurse detect unexpected or preventable adverse reactions and readjust the initial care plan to make it more effective.
Some nursing educators or instructors often ask students to include one additional element in their care plans: rationale is where students use scientific evidence to justify their clinical decisions. In most cases, students are required to use the latest findings published in the last 3-4 years.
Care plan examples can improve students’ critical thinking, creative and analytical skills. They can also prepare students to operate in a challenging clinical environment. They can be treated as the worst of all evils, but they are unavoidable for those who decide to devote themselves to nursing practice.