Nursing care plan

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A nursing care plan provides direction on the type of nursing care the individual/family/community may need. It is initially compiled of a set of assessment tools, which begins the process of gathering information to determine appropriate mediation. A process of setting goals is also initiated to help with the evaluation of care, which is modified after nursing interventions are implemented.[1] It is a set of actions the nurse will apply to resolve/support nursing diagnoses identified by nursing assessment.[2] The creation of the plan is an intermediate stage of the nursing process. Nursing care plans provide continuity of care, safety, quality care and compliance.[3]

Nursing care plans promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. If a nursing care is not documented within the nursing care plan then insurers will not pay for the hospital/ home/ nursing home care that was received by the individual.[4]

Objective[edit]

  1. To promote methods, evidence-based, holistic care.
  2. To record care.
  3. To measure care.[1]

Characteristics[edit]

  1. Its' focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.
  2. It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.
  3. It focuses on client-specific nursing outcomes that are realistic for the care recipient
  4. It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.
  5. It is a product of a deliberate systematic process.
  6. It relates to the future

Elements[edit]

The nursing care plan consists of a nursing diagnosis with defining characteristics (subjective and objective data that support the diagnosis), related factors or risk factors, expected outcomes/goals, and nursing interventions.[5]

See also[edit]

References[edit]

  1. ^ a b Ballantyne, Helen (24 February 2016). "Developing nursing care plans: Nursing Standard". RCNi. 
  2. ^ Nursing and Midwifery Board of Australia, NMBA (1 January 2016). [file:///C:/Users/20163022/Downloads/Nursing-and-Midwifery-Board---Standards-for-Practice---Enrolled-Nurses.PDF "Standards for Practice- Enrolled Nurses"] Check |url= value (help) (PDF). Enrolled nurse standards for practice- Nursing and Midwifery Board of Australia. Nursing and Midwifery Board of Australia. 
  3. ^ Keenan, G., Yakel, E., Tshannan, D., & Mandeville, M. (2008). Patient Safety and Quality: An Evidence Based Handbook for Nurses. Rockville, MD: Hughes, R.G. pp. Chapter 49. 
  4. ^ RN Central (2016). "What is a nursing care plan and why is it needed?". RN Central. 
  5. ^ Gulanick Meg, & Myers Judith (2014). Nursing Care Plans 8th Edition. Mosby.