What is a Nursing Care Plan?
A nursing care plan contains relevant information about a patient’s diagnosis, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and an evaluation plan.
Over the course of the patient’s stay, the plan is updated with any changes and new information as it presents itself. In fact, most hospitals require nurses to update the care plan during and after each shift.
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What is the Purpose of a Nursing Care Plan?
Nursing care plans help define nursing guidelines and some treatment guidelines (as ordered) for a specific patient.
Essentially, it is a plan of action. It helps guide nurses throughout their shift in caring for the patient. It also allows nurses to provide attentive and focused care.
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Types of Nursing Care Plans
There are four main types of nursing care plans.
- Informal – A care plan that exists in the nurse’s mind and is actions the nurse wishes to accomplish during their shift.
- Formal – This is a written or computerized plan that organizes and coordinates the patient’s care information and plan.
- Standardized – Nursing care for groups of patients with everyday needs.
- Individualized – A care plan tailored to the specific needs of the patient.
What are the Components of a Nursing Care Plan?
Nursing care plans follow a five-step process:
- Assessment
- Diagnosis
- Expected outcomes
- Interventions
- Rationale and Evaluation
>> Related: The Nursing Process Explained
When writing a nursing care plan, you first have to determine what type of care plan you are interested in. If it is for your own use throughout the shift, then an informal one may be beneficial; however, if it is for the patient’s chart and required during your shift then an individualized care plan is the way to go.
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