In this lesson, you will learn the reasoning behind creating a nursing care plan. We will look at nursing care plan use during nursing school and clinical practice.
With successful completion of this lesson, you will:
- Know what a nursing care plan is
- Understand the reason nursing care plans are assigned in nursing school
- Understand nursing plans use in clinical settings
- Understand the nurse’s role in patient care planning
- Know the purpose of nursing care plans
- Champion the benefits of using a nursing care plan
What is a Nursing Care Plan?
A Nursing Care Plan is the way a nurse documents and communicates the Nursing Process.
Nursing care plans are one of the most common assignments in nursing school and can be a valuable resource in the clinical setting. They start when a patient is admitted and document all activities and changes in the patient’s condition. Using a care plan will encourage patient-centered care and make your nursing care more consistent. These plans are also a great communication tool among nurses, other healthcare professionals, patients, and their families.
Nursing students learn to assess a patient, make a nursing diagnosis, create a plan, implement the plan, and evaluate the plan to ensure best practices and outcomes. This process teaches them to problem-solve and make critical decisions. A nursing care plan helps nurses organize their day, know when things need to be accomplished, and balance their workload.
Nursing Care Plans in School
Nursing care plans are used to teach nursing students how to work through the nursing process, think critically, and provide patient-centered care. By writing things down, nursing students learn the basics of patient care and the building blocks for providing quality care.
Teach Critical Thinking
Critical thinking skills are an essential part of a nurse’s career. Writing out care plans help student nurses develop their critical thinking skills by making them think through each step of the nursing process and document it clearly.
When writing a nursing care plan, it is good to remember the seven basic skills of critical thinking:
- Decision making
Nursing care plans are key to providing patient-centered care and treatment. These plans assist nurses in providing individualized care and gaining a complete picture of a patient’s health.
Care plans outline the patient’s short- and long-term needs, recovery goals, and coordination requirements. They identify who is responsible for each part of the plan and can be used as a communication tool with medical staff, the patient, family members, and community or social services.
Nursing Care Plans in Clinical Practice
Care plans are used to teach nursing students how to individualize patient care, think critically, and learn the nursing process. Experienced nurses typically do this without documenting it. A formal nursing care plan can be a valuable tool for effective communication, and many healthcare facilities are beginning to utilize them formally.
Purpose of Nursing Care Plans
Nursing Care Plans are a written form of The Nursing Process. These plans ensure nurses deliver consistent, patient-centered, and holistic care. Each step in the nursing process is covered in the nursing care plan and helps nurses plan, implement, and evaluate nursing care.
The fives steps in the nursing process are:
- Assessment: The first step in delivering nursing care. It collects and analyzes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors data. A good assessment allows you to identify:
- Your patient’s biggest problem
- What needs to be addressed today
- Diagnosis: Using the data, patient feedback, and clinical judgment to form the nursing diagnoses. The diagnosis considers the patient’s signs, symptoms, pain, and the problems their condition has caused, such as anxiety, poor nutrition, conflict with family, and complications that may arise. The nursing diagnosis is the basis for the care plan. A good diagnosis should:
- Be contain patient-centered, holistic interventions
- Focus on the patient
- Uncover the patient needs
- Planning: Setting short-term and long-term goals based on the nurse’s assessment and diagnosis. Ideally, with input from the patient. This is where you determine nursing interventions to meet these goals. A good plan should:
- Define patient goals
- Identify what would get them closer to their goals
- Be a guide to whether the problem has improved
- Define what a patient can effectively accomplish
- Implementation: Implementing nursing care according to the care plan, based on the patient’s health conditions and the nursing diagnosis. This is where you will document the care the nurse performs. A good implementation should:
- Define the nurse’s role
- Help you understand your role in their recovery
- Be different from the Provider’s role
- Evaluation: Monitoring and documenting the patient’s status and progress towards meeting the planned goals. This allows you to modify the care plan as needed. A good evaluation should:
- Provide continuity of care
- Promote communication between nurses and shifts
- Move everyone towards the same goals
Alright guys, in this lesson I’m excited to explore the actual purpose of nursing care plans.
It can be really frustrating to be in school and hear nurses say things like “you’ll never do nursing care plans in real life”. It makes you feel like you’re absolutely wasting your time, right? Well our goal in this lesson, and in this whole course is to help you understand the real purpose of nursing care plans and how they can help you throughout school and beyond. We truly believe nursing care plans are SO invaluable to provide really incredible care for your patients, it’s just that the process evolves over time as you gain more experience. So we’ll dive into that here and in the rest of this course, and we’re going to make you guys believers as well.
So the big thing you’ll notice is that nursing care plans look different when you’re in school versus when you’re in clinical practice. This is part of the reason why you’ll hear experienced nurses tell you you’ll never do one. Well in the lesson on using nursing care plans in clinicals, we’ll dive deeper into that. But, for now, I just want to help you understand some of the high level major differences. When you’re in school, you are most likely writing these care plans in some sort of specific format. They may have a table for you, or a chart, or a form to fill out. It’s always patient-centered – what is going on today with your patient and what do you need to do about it. The ultimate goal of creating these nursing care plans in school is to help you learn to think critically. In clinical practice, it’s usually not written, but it’s still happening! It’s still patient-centered, and it still serves its purpose. So let’s explore in more detail the overall purpose of these nursing care plans.
The first thing nursing care plans will help you do is to identify your priorities. Once you’ve gathered all your information, you can determine what your patient’s biggest problem or problems are. What issues need to be addressed before the others. It’s also important to be thinking about what problems or issues you may actually be able to address today, as opposed to those long-term things. We’ll look in more detail at how to evaluate this when we talk about how to write a nursing care plan.
Once you’ve identified your priorities and the issues you want to address, you can start to choose interventions. What do you need to do to address those issues? Also – again, think about what you can do to get them closer to their goal TODAY.
Speaking of goals – nursing care plans help us to define those patient goals. Think of this in terms of how you would know that this issue isn’t an issue anymore? Or what would be the evidence that it’s improving. And, as always, think in the short term as well as long term. What kinds of things can my patient possibly accomplish TODAY. We’re not going to see a wound decrease in size by 50% in one day, right? But maybe we could see it NOT get larger, or NOT show signs of infection, right? That could be our patient’s goal for the day.
Nursing care plans also help us to define our unique role in the care of the patient. Sometimes we get so focused on following provider orders, like administering medications, that we forget that our role is much bigger and much more holistic than what the provider sees. So it’s important to think about everything we can do for this patient, not just what medical treatments they need.
Lastly, and truly most importantly, nursing care plans help to provide continuity of care. When we communicate this plan of care between nurses or between shifts, we can make sure everyone is on the same page and moving towards the same goals! It also helps to say “this is what I saw, this is what I did about it, and this was the outcome – so we’re a little closer to where we wanted to be”. We have to work together as a team to get the patient where they need to be.
Like I said – we want to make you a believer in the importance of care plans. So just to recap the major purposes – Nursing Care Plans help us to identify priorities for the patient, choose appropriate, holistic, patient-centered interventions that help us reach those patient goals we defined. They also help us to define our unique role as nurses and to provide continuity of care between nurses so that we’re all on the same page.
So, don’t get bogged down in the detail or the formality of a nursing care plan. Remember that there is a much larger purpose at play here that ultimately leads us towards better patient outcomes! In the rest of this course we’re going to explore a 5-step process to writing nursing care plans and we’re going to work a BUNCH of examples with you so that you can feel super comfortable. Make sure you check out our Care Plan Library of over 130 Nursing Care Plans. Use these as a guide to help you plan specific patient-centered care for YOUR patients. Now, go out and be your best selves today. And, as always, happy nursing!