Nursing care plans give nurses a way to track patients' progress and provide appropriate treatment. Because nurses work with multiple patients per day, they rely on care plans to quickly access a patient's history, diagnosis, and treatment plan.
Care plans are thorough documents that include an initial assessment of the patient, medical diagnoses, goals for recovery, specific treatment plans, and the patient’s response to treatment. Because multiple nurses will work with the same patient, the care plan needs to be specific enough for any nurse to be able to pick it up and effectively continue the care for the patient. As a patient's treatment progresses, the care plan must change to reflect the most current condition and intervention strategies.
The nursing care plan is an essential part of patient care. It consolidates a patient's present diagnosis, physical assessment, history, and medical records into a clear plan of action. A care plan offers a holistic approach to patient care and continues to evolve until the patient is discharged.
An effective care plan includes important patient information and offers specific, measurable goals for treatment. While the exact format may vary by hospital or care center, a thorough nursing care plan generally includes the following categories:
Comprehensive assessment: This section includes objective and subjective patient information, such as age, symptoms, and medical history
Problem list: Here, the medical diagnoses and other issues affecting treatment, such as family problems and eating habits are listed
Planning and interventions (treatment): Details of the specific goals and instructions for patient care that can be followed by any member of the nursing staff are included here
Evaluation: Reports of the measures to complete and tests to perform to evaluate patient's response to treatment are listed in this section
As a patient works toward recovery, the care plan should be frequently reevaluated and updated. An effective care plan should also feature:
Because hospitals are frequently understaffed and nurses are overworked, many tools exist to help nurses efficiently prepare care plans. Nursing care plans resources include care plan software, websites, and books that provide "stock" care plans and templates for creating personalized patient plans. Using these tools, nurses can quickly create thorough care plans and minimize the chance of error.
Proper training is essential for creating actionable care plans. Registered nurses with a thorough understanding of diseases, treatment options, evaluation methods, and patient care are generally responsible for developing and updating care plans. To become a registered nurse, you must graduate from an accredited nursing program, pass a national licensing exam, and become licensed in your State.
The most common paths to nursing include earning an associate's degree in nursing (ADN) or a Bachelor of Science in Nursing (BSN). ADN programs typically take 2 to 3 years to complete and include both clinical experience and coursework in nursing, anatomy, physiology, chemistry, microbiology, nutrition, psychology, and behavioral sciences. BSN programs take about 4 years to complete and supplement ADN coursework with communication, critical thinking, and leadership training, as well as additional clinical practice.
Nursing care plans must always be customized for each patient. In a perfect world, nurse staffing ratios would allow nurses unlimited time to sit at a desk and utilize their expertise. In this perfect world, each nurse would also have time to create a complete admission to discharge. This would include a detailed home care plan developed based on patient history, medical records, physical assessment, and applicable nursing diagnosis. Unfortunately, we live in an imperfect world.
Hectic nursing shifts do not allow adequate time to research each patient's history and write a comprehensive care plan from scratch. Understaffed nursing teams try to keep up, but when time is limited, mistakes can happen. The below "stock" care plans, care plan software, and nursing care plan books are useful as reference tools to help prevent mistakes from happening when a nurse creates a patient-specific care plan.