Nursing Care Plan Lecture Notes

Introduction

• Topic: Nursing Care Plan (NCP)
• Importance: Essential for student nurses and nurses in patient care.

Learning Objectives

After 45 minutes, learners will be able to:

• Describe what a nursing care plan is.
• Differentiate the four different types of nursing care plans.
• Translate objectives of nursing care plans.
• Distinguish the purpose of nursing care plans.
• Systematize the components of nursing care plans.
• Relate examples of nursing care plans.

Definition of Nursing Care Plan

• A formal process that identifies existing and potential needs/risks of patients.
• Facilitates communication among nurses, patients, and other healthcare providers.
• Quality and consistency in patient care depend on the nursing care planning process.

Nursing Process

• Mnemonic: ADPIE
  • Assessment
  • Diagnosing
  • Planning
  • Implementing
  • Evaluating
• Importance: Helps identify patient needs effectively.

Types of Nursing Care Plans

1. Informal Nursing Care Plan
   • Exists in the nurse's mind, often used by experienced nurses.
2. Formal Nursing Care Plan
   • Written or computerized guide organizing client care.
3. Standardized Care Plan
   • Focuses on groups of clients with similar needs, e.g., family care plans.
4. Individualized Care Plan
   • Unique to each patient based on their specific needs.

Objectives of a Nursing Care Plan

• Promotes evidence-based nursing care.
• Supports holistic care (physical, psychological, social, spiritual).
• Establishes care pathways and care bundles.
• Identifies goals and expected outcomes (short-term and long-term).
• Facilitates communication and documentation of care plans.
• Measures nursing care effectiveness.

Purposes of a Nursing Care Plan

• Defines the nurse's role in patient care.
• Provides direction for individualized patient care.
• Guides staff assignment to specific patients.
• Ensures continuity of care through effective documentation.

Components of a Nursing Care Plan

1. Assessment
   • Collection of subjective and objective data.
2. Nursing Diagnosis
   • Clinical judgments based on assessment data.
3. Scientific Analysis
   • Explains the nursing diagnosis and its implications.
4. Goals of Care
   • Outlines what the nurse hopes to achieve.
5. Nursing Interventions
   • Actions taken to achieve patient goals.
6. Rationale
   • Scientific explanation for each intervention.
7. Evaluation
   • Assesses effectiveness of the interventions and whether goals were met.

Writing a Nursing Diagnosis

• Format: PES (Problem, Etiology, Symptoms)
  • Example: "Impaired physical mobility related to decreased muscle control as manifested by inability to control lower extremities."

Nursing Interventions

• Types:
  • Independent: Actions initiated by the nurse.
  • Dependent: Actions based on physician's orders.
  • Collaborative: Actions taken in cooperation with other healthcare professionals.
• Must be specific, measurable, attainable, realistic, time-bound, effective, and rewarding (SMARTER).

Evaluation of Nursing Care Plans

• Ongoing assessment of patient progress toward goals.
• Categorization of goals: met, not met, or partially met.
• Importance of revising plans based on evaluations to ensure patient-centered care.

Sample Nursing Care Plan Overview

• Structure of NCP:
  1. Defining characteristics (subjective/objective data)
  2. Nursing diagnosis
  3. Scientific analysis
  4. Goals of care
  5. Nursing interventions with rationales
  6. Evaluation of outcomes

Conclusion

• Importance of a complete assessment in developing NCPs.
• Continuous improvement through practice and acceptance of feedback.

References

• Don Justin Vera (APA 7th edition)