The third phase of the nursing process is planning. It is when problems are prioritized, goals and desired outcomes are formulated, nursing interventions are prepared properly, and it is also when nursing orders are documented. The end product for this phase is the development of a nursing care plan.
A nursing care plan could either be formal or informal. It is considered an informal nursing care plan if it only corresponds to what the nurse has in mind about the client’s health status which she integrates it to her plan of care. On the other hand, it is known to be formal, if it follows an organized guide wherein the client’s information is supplied.
This type of care plan could be written or computerized, depending on the institution’s guidelines. A formal care plan is commonly used because it allows nurses to delineate the progress of the client’s health status with the given nursing interventions in the plan of care. It also makes nurses permissible to add up better plans for the client or to eliminate ineffective interventions; reflecting to which goals are achieved upon evaluation of care. In short, it could benefit shifting nurses efficiently for it allows continuity of care for the designated client.
Furthermore, a nursing care plan could also be standardized for all sorts of clients with the same needs and it can be individualized considering the varying needs of each client. A standardized nursing care plan relies on the standards of care for perusal when the need in the facility arises. The care given is achievable because it corresponds to nursing actions utilized for clients with the same medical condition.
It does not, however, refer to the ideal plan of care which is individual in nature. In connection to that, it does not include medical interventions, which means that it is solely for nursing practice and mitigates nursing accountability. These standardized care plans and standards of care are pre-printed to guide nurses well during the 3rd phase of the nursing process.
Formats of the nursing care plans vary depending on institutions. Perhaps, it is often utilized with four divisions, including the nursing diagnosis, nursing goals, and desired outcomes, nursing orders/ actions, and the evaluation column. Sometimes it could be found with three columns, in which the evaluation is done in the goals column. Meanwhile, it can also be a five-column plan if the institution adds a column for assessment data, which precedes the nursing diagnosis column. In student care plans, a rationale is usually included since it is considered as part of their learning activity.
Guidelines for Writing a Nursing Care Plan
- It is important to include the date when the NCP is written because it allows easy updating of nursing interventions thorough evaluation and review of the plan of care. The nurse who wrote it should put her sign to indicate that she was the one who did the said nursing interventions in the nursing care plan.
- It is also advised to organize the care plan in accordance with the guidelines of the hospital. It would beneficial if it is outlined and categorized well in a given standardized format.
- The nurse is encouraged to utilize medical terms and symbols in writing instead of using a complete set of sentences.
- The plan of care for the client should be specific and clear to avoid miscommunications between nurses who handle the client.
- The nurse could also refer to procedural tools like source books for procedures that need to be included in the nursing care plan. It is unlikely if the step by step procedure will be indicated in it.
- The preferences of the client should also be considered in the plan of care. It is then individualized according to the client’s views or choices in treatment modalities.
- Nursing care plan does not only act on the present health issues of the client, prevention, promotion, and restoration of health should also be included.
- It should also contain an ongoing assessment for the client.
- Though it primarily involves nursing actions, collaborative interventions should also be contained in it to emphasize too, the functions of other health team members in the provision of care.
- And lastly, discharge and home care needs should also be addressed, involving health educations and plans upon discharge.
- Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Fundamentals of Nursing: Concepts, Process and Practice.7th Edition. Pearson Education Inc.