All of us have a fantastic superpower called planning. We plan our vacations, meals, and what we’ll wear on the weekend. We plan our careers and retirements. The only thing we don’t plan is perhaps a lazy Sunday afternoon.
And honestly, planning and organizing ahead of time makes life so much easier. For instance, to be able to make your delicious creamy homemade hummus, you know you have to soak chickpeas the night before. Every line of work needs some exceptional organizational skills to ensure smooth and seamless operations.
Case in point: In an environment as complex as a hospital or other medical setting, having a plan isn’t just an inclination. It’s a must. When it comes to nursing, specifically, plans ensure quality, consistent patient care through a streamlined process that helps medical professionals assess patients’ needs, identify risk factors and react to changes in a person’s conditions. Nursing care plans keep medical settings running smoothly.
Here we’ll explain some nursing care plan examples to show how different healthcare institutions ensure the highest level of patient care possible.
What’s a nursing care plan?
A nursing care plan, or NCP, is a problem-solving approach to nursing interventions. Registered nurses (RNs) use these plans to identify and treat patients’ conditions.
Nurses informally plan in their heads constantly. But the types of plans we’ll explore are formal ones, some of which are standardized to meet the needs of specific conditions and others are individualized and tailored to an individual’s needs.
This all may leave you wondering, isn’t a care plan what nurses do when they chart a patient? In some ways, yes. Not all healthcare environments have formal care plans because they consider them more paperwork (and nurses already do a lot of that).
But there’s a good case for formal plans, especially in long-term care environments like nursing homes. They support evidence-based practice, help streamline communication on a patient’s condition across staff members and measure the efficacy of nursing care (more on that in a bit).
Why do you need a nursing care plan?
If the medical setting in which you work always has a way of checking off all the needs below, you may be implementing nursing care plans without calling it such. Here’s a list of reasons why you should have a nursing care plan in place. NCPs:
- Facilitate standardized, comprehensive, effective care: A nursing care plan ensures all medical professionals get the same information about the patient, which helps them provide thorough care to the patient.
- Make sure that care is patient-centered: This helps nurses and other medical professionals to be in sync with each other and assist the patient at all times. Even if the patient needs specialized care with respect to their physical or physiological conditions, the plan helps the nurse assigned to support them.
- Keep excellent records: The care plan helps nurses maintain the patient’s medical records with utmost clarity. These records act as evidence that the patient received care.
- Define a nurse’s role in the care process (as well as the roles of other team members): A well-written care plan ensures that everyone responsible for taking care of the patient is well-aware of their roles and duties.
- Engage patients in their own care plan: This helps patients understand the importance of their health conditions and how they can improve their well-being.
- Measure the efficacy of care: It’s important to regularly assess the patient’s condition to keep check that they’re improving or that the plan created for their care is working.
- Help nurses set goals for care: Once the diagnosis has been made, it’s the nurses’ responsibility to set goals for themselves, ensuring quick improvement in the patient’s condition. These goals can be both short-term and long-term.
- Encourage collaboration across the care team: This enables all the members of the team to support each other while providing direct patient care. Since all team members have access to the patient’s medical history and records, it makes it a whole lot easier for them to take care of the patient.
- Ensure compliance: This is one of the important aspects of a nursing care plan as it demonstrates the improvement graph of a patient. This documentation is proof that the patient received good care.
How to create a nursing care plan
Nursing care plans are based on the five elements of the nursing process. Here’s what they are and how they relate to the plan (nurses should fill out the information on each element when admitting a new patient):
- Assessment: Review a patient’s state and any lab data or diagnostic testing results. In short, this is the patient’s medical history to check if the patient has any allergies to medicines or a particular type of food.
- Diagnosis: Form a nursing diagnosis based on the assessment data and information from the patient.
- Outcomes and planning: Outline the desired outcomes in a plan based on SMART goals in nursing (Specific, Measurable, Attainable, Realistic, and Time-Bound). If you want to practice nursing goals examples, you can try projecting them for common health conditions.
- Implementation: Implement the care plan by performing nursing interventions under the supervision of a physician. Nursing interventions can be anything from changing a patient’s resting condition to monitoring fluid consumption. There are seven intervention domains: family, behavioral, physiological, complex, community, safety, and health system.
- Evaluation: Monitor the patient’s progress to evaluate whether or not the plan has fulfilled the nursing outcomes. Make changes to the plan as needed, as updates are important not only for you but also for other care team members.
Examples of nursing care plans
Typical nursing care plans take the five elements of the nursing process and spread them out across an easy-to-read chart. These formats generally contain three or four columns, although some may have more. If you’re just getting started as an RN or a nursing student who’s new to the practice, try using a template for one of the following formats. You can also check out sample nursing care plans to get the hang of making your own.
- The three-column format: This format contains the fundamentals. The first column houses information on the medical diagnosis, the second on outcomes and evaluations, and the last on interventions.
- The four-column format: In this one, the first column contains information on the diagnosis, the second on nursing goals and outcomes, the third on interventions, and the final on evaluation.
- Longer formats: These may include an entire section on the nursing assessment and an additional one on rationale.
Take Maslow’s Hierarchy of Needs into consideration
A nursing care plan must be made with the patient’s needs at the center. These plans exist so that healthcare workers and institutions can ensure positive patient outcomes and quality care. Maslow’s Hierarchy of Needs can serve as an essential reference and reminder of the critical points of care and primary objectives of a nurse. Here’s a list you can follow:
- Basic physiological needs: Nutrition, toileting, breathing, circulation, sleep, sex, shelter, and exercise.
- Safety and security: Injury prevention, suicide precautions, fall precautions, car seats, trust, safety, and patient education.
- Love and belonging: Methods to avoid social isolation and foster active listening, therapeutic communication, and intimacy.
- Self-esteem: Acceptance in the community and workforce, acknowledgment of personal achievements, sense of control or empowerment, and accepting one’s physical appearance.
- Self-actualization: Growth, empowerment, ability to recognize the point of view of others and reach one’s maximum potential.
Practice effective communication
One of the key functions of a plan is to get the whole care team on the same page. You can bolster your use of the care plan by practicing your effective communication techniques. Here are the 10 facets of great communication:
- Verbal communication
- Nonverbal communication (gesture)
- Written communication
- Active listening
- Presentation skills
- Personal connection
- Patient Education
- Cultural awareness
If you want to foster even more skills that’ll help you ace your career and show your empathy, compassion, competence, and achieve your professional goals in nursing, you can check out our top 10 tips for nurses.
At Jaanuu, we’re always here to support you in your healthcare career, not just with hardworking scrubs. We have plenty of tips on how to get through your toughest days at work and take care of your mental health. Check out our advice for surviving the night shift or pointers on how to deal with difficult patients.