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A nursing care plan is an important part of nursing education. The ability to write
a nursing care plan is a skill that is used throughout a nurse's career, regardless
of her specific field or area of expertise. Emphasizing the importance of nursing
care plans is heard in many nursing classrooms, but to help nursing students better
appreciate why nursing care plans are an important part of patient care, they should
first understand what a nursing care plan is and how it's used by a patient's health
care team.
What is a nursing care plan?
A nursing care plan is a plan of action developed by a nurse of nursing team in order
to provide care for a patient. A nursing care plan consists of a nursing diagnosis,
risk factors, goals, and nursing interventions. The nursing interventions are the
actual care steps taken to work toward the goals. It is developed after evaluating
and diagnosing the patient. The nurse develops steps that will help care for the
patient and work toward health goals set by the patient and health care team. In
some cases, the patient's family and/or friends are also involved in setting health
goals.
Along with the actionable steps to reach the patient's goals, a nursing care plan
also helps the nurse evaluate the patient's care, as well as determining whether
or not the patient's health goals were met, and why. A nursing care plan is part
of the nursing process, which usually begins with an assessment and diagnosis of
the patient, and ends with an evaluation.
Generally, nursing care plans are thought of as caring for an individual patient,
but they can be implemented to care for a family, group, or community, as well.
How are nursing care plans used?
Nursing care plans are used to ensure that members of the patient's care team are all
on the same page regarding his or her care. That is, a nurse on a different shift can
look at the patient's care plan and know what needs to be done for him or her. A doctor
can look at the nursing care plan to ensure it lines up with how the doctor is treating
the patient. A nursing care plan helps keep the health care team organized, and gives the
nurse something to point to when the patient or his or her family asks about progress
toward health goals. Nursing care plans also provide a record of how the patient was
cared for, which can be looked at in order to later evaluate the patient's progress
and make any changes needed. If there are any questions later about a particular intervention
or its effects on the patient, the nurse can look at the nursing care plan for answers.
How are theories and models integrated into nursing care plans?
How theories and models are integrated into a nursing care plan depends on the specific
theory or model used. Many nursing theories and models directly relate to how a nursing
care plan is developed. In order to integrate those plans, the nurse uses the philosophies
of care in the theories and models to create the plan. That is, in the Self-Care Deficit
Theory, the nursing care plan will allow the patient to care for him or herself as much
as possible. Nursing models that focus on the relationship between the nurse and patient
are usually integrated into the nursing care plan naturally rather than consciously. The
relationship the patient has with the nurse will affect the nursing care plan, but the
nurse will not do anything differently for it to happen. Some nursing theories or
models may not apply to the nursing care plan, but are instead focused on the patient's
diagnosis or evaluation.
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