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Nursing care plans (NCPs) are an important concept to understand if you want to pursue a career as a nurse. Nurses, patients, and other healthcare providers can all benefit from a nursing care plan that facilitates communication.

A nursing care plan contains information about the patient's diagnosis, treatment goals, nursing orders (including what observations and actions must be performed), and an evaluation plan.

Throughout the patient's stay, the plan is updated to reflect any changes and new information that may arise. In most hospitals, nurses have to update the patient's care plan during and after their shifts.

Is a Nursing Care Plan Necessary?

Nurse guidelines and some treatment guidelines can be defined as part of a patient's nursing care plan.

It's a strategy for achieving a goal. The plan serves as a guide for nurses as they care for the patient during their shift. Additionally, it helps nurses to devote more time to patient care.

Nursing Care Plan Types

Nursing care plans can be divided into four main categories.

• For the most part, informal plans are just that, ideas floating around in the nurse's head about what she wants to do during her shift.
• Organized and coordinated patient care is best accomplished through the use of a formal, written, or computerized plan.
• Nurses provide the same routine level of care to a large number of patients.
• A care plan that is tailored to the patient's specific needs.

Creating a Care Plan

A nursing care plan must first be determined by the type of care you are looking for. It's okay if you only use it for yourself. However, if it's for the patient's chart and you need it for the duration of your shift, then an individualized care plan is the better option.

Start with an evaluation

Gathering data, both subjective and objective, is an important first step in creating an organized care plan. You can get this information from anywhere.

• The patient's and their loved ones' statements.
• Signs of life.
• Complaints about your body.
• Conditions of the body.
• A background in medicine.
• Weight and height.
• Ingestion and expulsion.

Get a proper diagnosis

The data and information gathered in “Step 1” are used to select a nursing diagnosis that is most appropriate for the patient and the goals and objectives of the patient's hospitalization.

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When it comes to diagnosing nursing problems, the North American Nursing Diagnosis Association (NANDA) says that nursing diagnoses are “a clinical judgment about the human response to health conditions/life processes.”

Outcomes and Preparation 

SMART goals, based on evidence-based practices, should be developed after the nursing diagnosis has been established. A SMART goal is a specific, measurable goal that can be achieved within a reasonable amount of time. All of the information gathered should be taken into account when making a decision about the patient's treatment.

Implementation

It's time to get to work on helping the patient achieve their goals now that they've been established. Patients with constipation, for example, may benefit immediately from the use of an over-the-counter laxative suppository. But results from other interventions may not be seen for several days or even weeks.

Review and Recommendation

The evaluation phase is the fifth and final step in the nursing care plan. This is the time to see if the shift's goals have been met. Three outcomes are possible:

• Met.
• Ongoing.
• Achieved.

The results of the evaluation are used to adjust the program's objectives and interventions as necessary.

A nursing care plan can be written in a variety of ways

It takes time and practice to write a nursing care plan. It's a skill you'll learn in nursing school and use for the rest of your professional life. In order to determine the nursing diagnosis, you must first conduct an assessment of your patient. Using a NANDA-approved diagnosis, determine the patient's expected and anticipated outcomes. Finally, put the plans into action and assess whether or not the desired outcome was achieved.

What does the nursing care plan accomplish?

Nurses, patients, and other healthcare providers can all benefit from a nursing care plan that facilitates communication.

A nursing care plan consists of what exactly?

Patients' assessments, treatment goals, and interventions are all included in nursing care plans. Observations are also included. Subjective and objective data can both be included in these observations.

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