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By What Is A Nursing Care Plan & There Types?
A nursing care plan is one of the most ordered and vital documents designed for nursing staff. However, this study discusses the patient’s healthcare needs, goals, and nurse interventions.
Types of Nursing Care Plan
When it comes to creating nursing care plans, there are different variations used in the practice. Moreover, the structure and format of a care plan depend on why you are writing a care plan and the healthcare setting.
Basically, there are four types of nursing care plans. They include:
- Formal Care Planning
- Informal Care Planning
- Standardized Care Planning
- Individualized Care Planning
Come on! Let’s explore each one of them in detail:
Formal Care Planning
Formal care planning means documenting the patient records which are used to coordinate, prioritise and maintain continuity of care.
Furthermore, these plans are also modifiable depending on new priorities or the outcomes of interventions. However, they are often related to the longer-term goals of the patient.
It might include goals to meet before discharge from the hospital or any other service. In addition, this is also used within the framework of the nursing process.
Informal Care Planning
So, informal care planning refers to the arrangements and considerations made by patients and their families. It is basically an unpaid care provided by family members, friends, or neighbors to support someone who needs proper care.
This care planning is a bit different than the plans created by healthcare professionals and companies.
Additionally, Informal care planning often involves practical and emotional support, helping with basic tasks, giving medication, and overall mental and physical well-being.
Furthermore, they might include the nurse’s goals for their shifts, which can be changed depending on the day’s priorities or changes in the patient’s condition.
Standardized Care Planning
Care plans are either standardized or individualized. Now, what does that mean? Well, the standardized care planning is used in such settings where a specific patient’s conditions require consistent care.
For example:
A Standardized care plan is used in the post-operative care pathway in the post-surgical unit. Additionally, the postoperative care plans outline expected goals for each post-op. However, these care plans should be tailored, when possible, to the needs of the individual patients.
The essential components of this type of care planning include:
- Consistency, ensuring every patient gets the base level of help.
- Efficiency reduces the time nurses need to spend on developing care plans.
- Moreover, it can also improve the process of documentation. Also, it makes sure that the nursing records are complete.
- It can be adapted to create tailored nursing plans for the patients.
Individualized Care Planning
Lastly, individualized care planning is the last type of nursing care plan. It is created for individual patient needs. Moreover, these plans should include the input from the patient whenever possible.
Why?
Well, it helps create personalised goals and support patient needs. Additionally, when creating an individual care plan, you have to consider the patient’s health status, history, and motivational factors. Also, you have to inquire about what matters most to them.
Moreover, they include the patient’s input wherever needed in the care planning. They are built on the foundation to provide treatment based on one’s health and medication plans. Also, they might include the elements of standardized care planning.
How To Write A Nursing Care Plan:
Assessment:
Begin by thoroughly evaluating the patient’s physical. In addition, there are social, psychological, and environmental elements. Data collecting processes include interviews, diagnostic tests, physical exams, and patient histories.
Diagnosis:
Nursing diagnoses sometimes differ from medical diagnoses. In the nursing diagnosis, they focus on actual or potential health issues. Use standard nursing diagnosis terms, such as NANDA-I (North American Nursing Diagnosis Association International).
Setting Priorities:
Prioritise nursing diagnosis based on the patient’s current needs. This will classify them as high, medium, or low priority.
Goal Setting:
Setting specific and quantifiable goals is important for each nursing diagnosis. However, its goals should be patient-centered. Also, specific, measurable, achievable, relevant, and time-bound i.e. (SMART). They represent the desired patient outcomes.
Intervention Planning:
Outline nursing interventions. Which are nurses’ acts and activities to assist patients in meeting defined goals. Interventions should be evidence-based and adhere to best practices.
Implementation:
Complete the nursing interventions as indicated in a flawless nursing care plan. Document every action you perform, as well as the patient’s response.
Evaluation:
Continuously assess the patient’s progress toward the specified goals. However, if the goals are met, adjust the treatment plan accordingly. If not, review and modify interventions as necessary.
Tips For Writing Effective Nursing Care Plans:
Individualization:
Nursing care plans should be properly customized. Nursing plans must be aligned according to each patient’s unique needs. They must be designed according to the circumstances, rather than adopting generic templates. Therefore, to avoid misinterpretation, goals, express diagnosis, and interventions in clear and simple language, without using jargon or unclear words. Nursing Assignment Writers UK can best facilitate in creation of the most effective nursing care plan.
Evidence-Based Practices:
However, it is important to make sure of your nursing interventions. Which are based on current evidence and for best practices. Therefore, maintain current research and standards to provide the best care possible.
Patient Involvement:
Engage the patient and their family in the nursing care planning process. Which includes collaborative care planning that empowers people and encourages participation in their care.
Document thoroughly. Accurate and thorough documentation is also very critical. However, document all treatments, and evaluations in a clear, organized, as well as timely format.
However, nurses can create effective care plans that contribute to positive patient outcomes. Also, by following a systematic assessment, diagnosis, goal setting, intervention planning, implementation, and evaluation process.
Therefore, staying informed, communicating effectively, and involving patients Also, in the care planning process are also important components of successful nursing practice.
Nursing Care Plan Examples:
Sometimes all you need are a few examples to help you learn how to execute a difficult activity and to get the brain juices flowing. However, there are 3 care plans that I produced while in nursing school.
For example: Abdominal pain can be a minor issue or a medical emergency, with various causes and pathophysiologies. It can be acute or chronic. However, when a patient presents to the emergency department. Also, there are some patients in the outpatient environment with abdominal pain. Also, a thorough workup is usually required to determine the cause and pathophysiology.
The Causes Of Abdominal Pain:
Abdominal pain can be caused by pregnancy, ectopic pregnancy, trauma, a variety of gastric issues (gastroenteritis, constipation, diarrhea, irritable bowel syndrome, GERD, Chron’s disease, appendicitis, to name a few), hernias, allergic reactions, endometriosis, gallstones, severe menstrual cramps, hepatitis, miscarriage, and many others. However, there are many disease processes. Which causes stomach pain, and some patients may present with abdominal discomfort. Even if the clinical picture is not typical.
Diagnosis:
A nursing diagnosis is the foundation for developing and implementing an entire nursing care plan. However, after doing a thorough assessment. There is a need to develop a nursing diagnosis based on stomach pain-related issues. Choose the appropriate nursing diagnostic label. This kind of label can be obtained from the NANDA-I list. Which is recognised as a nursing diagnostic statements that corresponds to the patient’s signs and symptoms. One or more nursing diagnoses may be provided.
Planning & Outcomes:
However, nursing interventions are based on care plan goals. Therefore, it is important to consider these goals to be “what the patient will do” and clearly outline easy-to-measure, realistic descriptions of the patient’s expected outcomes.
In The Instance Of Stomach Pain, A Plan Could Include:
Return to regular bowel movements.
Eat and take meds.
Receiving fluids
Understanding the condition and treatment
Moreover, Implementations are the actions and activities you’ll do to attain the nursing plan’s objectives.
Implementations For Abdominal Discomfort May include:
Encourage evacuation!
Encourage eating.
Administer drugs as indicated.
Provide fluids.
Educate patients and family members.
Evaluation
However, a professional nursing plan is evaluated through an organized, continuing, and intentional assessment of progress toward specified goals and desired results. However, a thorough assessment of our care plan can help us decide. Whether to continue, discontinue, or adjust the interventions we’ve chosen.
For Our Abdominal Pain Example, An Evaluation Could Include:
The patient experienced two normal bowel motions.
The patient ate three meals.
Also, the patient took drugs.
The patient received fluids.
All the grasped information regarding the care.
Final Words:
You can design detailed treatment plans that address each patient’s individual needs.
Remember to use evidence-based practice, work with the healthcare team, and constantly evaluate and adapt the care plan as needed. However, with these techniques in place, you may successfully negotiate the complexity of care planning. Also, ensuring the best possible patient outcomes while also promoting the highest standards of nursing practice.
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