Nursing care plan

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A nursing care plan provides guidance on the types of care individuals or families may need. The main focus of the nursing care plan is to facilitate standardized, evidence-based and holistic care. Nursing care plans have been used for several years for human purposes and are now also used in veterinary professions. The treatment plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation.

According to British nurse Helen Ballantyne, treatment plans are an important aspect of nursing and they are intended to enable evidence-based holistic care. It is important to draw attention to the difference between care plans and care planning . Care planning is concerned with identifying problems and finding solutions to reduce or remove problems. The maintenance plan is basically the documentation of this process. This includes a set of nurse actions to be applicable for completing/supporting nursing diagnoses identified by nursing assessment. The plan of care allows the intervention to be recorded and its effectiveness assessed. The nursing care plan provides continuity of care, safety, quality care, and adherence. The nursing care plan promotes documentation and is used for replacement purposes such as Medicare and Medicaid.

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Destination

1. To promote evidence-based nursing care and to provide comfortable and familial conditions in hospitals or health centers.
2. To promote holistic care which means everyone is considered to be physically, psychologically, socially and spiritually in relation to disease management and prevention.
3. To support methods such as maintenance paths and maintenance bundles. The pathway of care involves the team's efforts to reach consensus with respect to the standard of care and expected outcomes while the treatment bundle is linked to best practice with regard to the care provided for a particular disease.
4. To record maintenance.
5. To measure treatment.

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History

The function of the nursing care plan has changed drastically over the last few decades. In 1953, treatment planning was not believed to be within the scope of nursing practice. In the 1970s, maintenance planning was activity-based. Patients are registered according to the procedures they have performed, which determine their treatment plan. Treatments are administered through word of mouth, makeup book, and work list. This form of communication all focuses on the activities the nurse does instead of focusing on the patient. Today, nursing care plans focus on a unique set of individual needs and goals. The treatment plan is individualized to create a patient-centered approach to care. Therefore, the nurse must perform a physical assessment before planning the patient's treatment.

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Component care plan

The treatment plan includes the following components;

1. Client ratings, medical results and diagnostic reports. This is the first step to be able to create a maintenance plan. Especially client judgments are related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age, economic and environmental. Information is this area can be subjective and objective.
2. Expected patient outcomes are described. It may be long and short.
3. Nursing orders are documented in the treatment plan.
4. The reasons for the intervention to be evidence-based care.
5. Evaluation. It documents the results of nursing orders.

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Computerized nursing care plan

Computerized nursing care plans are a digital way of writing care plans, compared to handwriting. A computerized nursing care plan is an essential element of the nursing process. The computerized nursing care plan has improved the documentation of signs and symptoms, related factors and nursing orders. Using electronic devices when making nursing care plans more accurate, accessible, easier to complete, and easier to edit, compared with written and hand written care plans.

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See also

• Nurse scheduling issue
• Omaha System

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References

Source of the article : Wikipedia