Nursing care plans: overview and special writing tips

Introduction

A nursing care plan is a written plan about the care procedure for the patient. It has all the necessary information about the patient. The information includes the description of the treatment and checkup evaluation according to the patient’s health condition along with health problem diagnosis. Tutors Academy is a professional platform that helps nursing students in every matter of their lives. A nursing care plan helps in the good, organized, and flawless care of patients. This comprehensive guide provides a brief overview of the nursing care plans. It also discusses the important ways of writing nursing care plans. Nowadays, they are often computerized in the form of ready-to-use printed documents.

Description of a nursing care plan

The nursing care plans convey all the essential information about the patients with their disease history and present state of health. It helps the nurses to know more about their patients along with necessary health facilities and care. It serves as a set of guidelines for nurses to deal with their patients. It also helps the nurses to keep sequential information about the progress of their patients.

What are the types of nursing care plans?

There are varieties of nursing care plans. The most used types of nursing care plans are given below:

Informal nursing care plans:  These are informal plans created by the nurses themselves. They help them remember their patients’ health history and the present and future strategies for the betterment of their health.  They are only in the minds of nurses and are not well documented. The nurses do not have to share these plans with others. It shows their creativity and professionalism to handle all types of problems quickly.

Formal nursing care plans: These plans are in well-written and computerized form. They provide the patient’s health history concisely and clearly. They are official files that circulate between the patient, nurses, and senior medical doctors. They are very useful for medical staff in complex and critical health situations. They can be updated easily.

Standardized nursing care plans: These care plans are officially prepared by healthcare organizations. They already have special guidelines for specific patients. They contain well-structured portions for patient conditions, diagnosis of health issues, and cure for the disease. They represent high-quality health services for the patients. The portions of the health care plan can be changed according to the requirements of the patients.

Individualized nursing care plans: These are plans created by healthcare professionals for each patient according to their different health histories. They are updated according to the health care preferences of the patient. They are centered on a specific patient. These plans are made for the most deserving patients. These care plans help in better care and service for the sake of these patients.

Important tips for writing a nursing care plan?

A nursing care plan is a concise history of a patient’s ailments having a cure. It shows the whole process of treatment for the patient. It is very beneficial for patients admitted to intensive care units in critical conditions. There are five steps to writing a successful nursing care plan.

Five steps of writing a professional nursing care plan

The successful process of writing a nursing care plan has five steps. They are the collection of data, health problem diagnosis, goals, implementation of care plans, and results evaluation.

Collection of data: In the first step, a nurse collects subjective and objective data about the patient. The data that is provided by the patient having feelings, concerns, and symptoms is called subjective data. On the other hand, the observations made by the nurses in the form of laboratory results, important signs, and physical symptoms are known as objective data. For example, if the patient tells about his medical history, medications, and self-care abilities, then the nurse collects subjective data. If the nurse notes down the measurement of a patient’s blood glucose, blood pressure, and health condition, then she collects objective data.

Health problem diagnosis: In the second step, the nurse analyzes the health issue of the patient. The problem is identified along with cures and medications. This is known as the process of nursing diagnosis.

Setting the Objectives: In the third step, the nurse determines the objectives of her services. The main aim of the nurse’s goals for his patient is within a limited time frame. These objectives are determined by following the SMART method. SMART stands for specific, measurable, achievable, relevant, and time-bound.

Implement the Healthcare Plans: In the fourth step, the healthcare plans are implemented to achieve the objectives of the treatment of the patient.

Analysis of the Results: In the fifth and final step, the nurse checks the results by checking the recovery status and present condition of the patient. If the results are good and satisfactory, then the patient is discharged from the hospital.

How to write an excellent care plan for nursing

• Use a nursing care plan that is most suitable for you.
• Use clear and concise language.
• Avoid jargon or abbreviations.
• Use relevant sources of evidence.
• Involve the patient in the healing process and respect his feelings.
• Encourage cooperation to create a flawless care plan.
• Update the care plan regularly according to the patient’s condition.
• Do critical thinking to add your points in the ready-to-use care plan.
• Focus on extensive care for improvement in the health of the patient.

Different ready-to-use forms of nursing care plans

A nursing care plan is essential for high-quality healthcare services. Tutors Academy is guiding high-quality nursing care plans to nursing students. They are very beneficial for nursing students. Nursing students all over the world have direct access to these high-scoring templates. Nursing care plan formats and templates have four columns including nursing diagnoses, outcomes and goals, nursing interventions, and evaluation. Some organizations have a three-column plan with goals and evaluation in the same column. There are different advantages and disadvantages to different formats and templates. Nurses must know about the purpose of nursing care plans according to the complexity of the patient’s health.  Some of the common ready-to-use forms for nursing care plans are:

Narrative form: It uses paragraphs and sentences to describe the parts of the care plan. It is comprehensive and flexible. It is time-consuming and difficult to read and update.

List form: It includes bullet points and keywords. It helps summarize the components of the care plan. It is concise and easy to update. It is easy to read.

Table form: It includes rows and columns to organize the components of the care plan. It is well-structured and clear.

Concept map form: It includes concept maps to explain the relationships between the different parts of the care plan. This format is visual and creative. It is easily understandable.

Electronic medical records (EMRs) for making electronic nursing care plans Electronic medical records (EMRs) are digital versions of paper charts. They have the medical history of the patients. EMRs can help nurses to generate nursing care plans easily. It provides the data in the form of evidence about diagnostic and laboratory tests. It includes the standardized usage of terminologies, such as NANDA-I, NIC, and NOC. They are easy to use according to the patient’s requirements.