Writing a great nursing care plan requires a logical approach to appropriately complete the sections needed for a care plan. A good care plan provides an excellent means of communicating among nurses, their patients, and other healthcare providers to attain health care outcomes.
Therefore, without a good nursing care planning process, quality, and consistency patient care will be lost. A nursing care plan starts when a patient is admitted to the health care and is frequently updated throughout in response to the patient’s changes in condition and evaluation of goal achievement.
Types of Nursing Care Plans
A nursing care plan can either be informal or formal. An informal nursing care plan is a strategy of action that exists in the nurse’s mind. A formal nursing care plan, on the other hand, is a written or computerized guide that puts information about the patient’s care in order. The formal care plans are further subdivided into standardized or individualized care plans.
A standardized care plan specifies the nursing care for a group of patients with everyday needs. An individualized care plan is one tailored to meet the unique needs of a particular patient or the needs that are not addressed by the standardized care plan.
A nursing care plan often includes nursing assessment, nursing diagnoses, planned goals and expected outcomes, nursing interventions, and rationales. However, in this post, we highlight only three components, which are diagnoses, interventions, and outcomes.
Diagnosis is the process where a nurse takes all the information gotten from the assessment component of the nursing care plan into consideration to determine the patient’s condition and medical needs. The diagnosis process entails a nurse making an informed judgment about the possible or actual health condition of the patient. several diagnoses can sometimes be made for a single patient.
Types of Diagnosis
There are four types of diagnosis and they include;
- Actual – Problem-focused
The actual or problem-focused diagnosis is the patient’s problem that is present at the time of the nursing assessment. The diagnoses are founded on the presence of related signs and symptoms. However, problem-focused nursing shouldn’t be viewed as more crucial than the risk diagnoses. More often, risk diagnosis can be the diagnosis with the highest significance for the patient. the actual diagnosis is based on nursing diagnosis, related factors, and defining characteristics.
- Risk nursing diagnosis
These are the nursing diagnoses that arise from a clinical judgment that a problem does exist. However, the presence of risk factors indicates that the problem is likely to develop unless there is nursing intervention. However, there no etiological factors for risk diagnosis. Components of risk nursing diagnosis include risk diagnostic labels and risk factors.
- Health Promotion
Health promotion diagnosis is a clinical judgment about desire and motivation to enhance well-being. These diagnoses are mainly concerned with the individual, family, or community transition from a certain level of wellness to a higher level of wellness.
- Syndrome Diagnosis
Syndrome diagnosis is a clinical judgment about a cluster of problem or risk nursing diagnoses that are predicted to present owing to a specific event or situation. These diagnoses are written as a one-part statement that requires only the diagnostic label.
In writing the nursing diagnostic section, describe the health status of an individual and the possible factors that have occasioned the status. However, you don’t have to include all types of diagnostic indicators.
The nursing outcomes describe what the nurse hopes to achieve by implementing the nursing interventions. The outcomes are derived from the patient’s nursing diagnoses. Outcomes provide direction for planning interventions while serving as criteria for evaluating patient’s progress. They also enable the patient and nurse to determine that the problem(s) has been solved.
Short Term and Long Term Outcomes
Nursing expected outcomes must be patient-centered and measurable. They should be developed by focusing on problem prevention, resolution, or rehabilitation. Outcomes are classified as either short-term or long-term. However, in acute care situations, most outcomes are short-term because of the nurse’s time spent on the patient’s immediate needs.
On the other hand, long-term outcomes are often appropriate for patients with chronic health problems or live at home or in nursing homes.
- Short-term outcomes: This is a statement differentiating a shift in behavior that can be attained immediately, often within a few hours or days.
- Long-term outcomes: These are outcomes that indicate an object to be attained over a longer period, often over weeks or even months.
- Discharging planning: This outcome entails naming long-term outcomes and therefore enhancing continued restorative care and problem resolution via physical therapy, home health, or different other referral sources.
When writing nursing outcome, you should focus on the following tips;
- Write outcomes in terms of patient’s responses and not as activities of the nurse
- Do not write outcomes on what the nurse intends to attain, but focus on what the patient can accomplish
- Use observable, measurable terms when writing outcomes. Therefore, avoid using vague phrases and words that need interpretation by the observer.
- Make sure the outcomes are compatible with therapies of other health care professionals
- Desired outcomes should be real for the patient’s capabilities, resources and limitations.
- Ensure each outcome is derived from only one nursing diagnosis
- Ensure that the patient considers the outcomes crucial and values them to ensure collaboration.
Nursing interventions are actions or activities that a nurse does to attain the patient’s goals or outcomes. The selected interventions should primarily focus on reducing or eliminating the etiology of the nursing diagnosis. For instance, in risk diagnosis, interventions should focus on reducing the patient’s risk factors.
Types of Interventions
- Independent Nursing Interventions
These are actions that nurses are licensed to engage in based on their sound judgment and skills. These interventions may include ongoing assessment, providing comfort, physical care, emotional support, and making referrals to other professional health care providers.
- Dependent nursing interventions
These include actions performed under the physician’s orders or supervision. They include the issuance of medications, diagnostic tests, intravenous therapy, diet, activity, rest, or treatment.
- Collaborative Interventions
These are actions performed by a nurse in collaboration with other healthcare providers such as doctors, dietitians, therapists, and social workers.
Note That: Nursing interventions should be:
- Achievable with resources and time available
- Safe and suitable for the patient’s health, age, and condition
- In line with other therapies
- In line with the patient’s values, beliefs, and culture
- Founded on nursing knowledge and experience
Writing excellent nursing care plan diagnoses, interventions and outcomes is the first step to getting higher grades, Besides, you will become a better nursing practitioner. However, if you are stuck with writing nursing care plan diagnoses, outcomes, and interventions, you can seek nursing care plan writing help.