care plan

A care plan is a document that summarizes a person’s current health conditions and treatments. The information listed below should be included in the care plan:

  • Health conditions
  • Medications
  • Healthcare providers
  • Emergency contacts
  • Caregiver resources

You can ask the person you’re caring for’s doctor to help you finish the care plan. At that time, you can also discuss advanced care plan options, such as what follow-up care is required, end-of-life care options, and available resources to help make things easier for you as a caregiver. To keep the care plan current, update it every year or whenever the person you care for’s health or medications change. Remember to respect the care recipient’s privacy after reviewing their personal information.

What Is a Nursing Care Plan?

A nursing care plan documents identifying a patient’s needs and facilitating holistic care, typically done in five steps. A care plan ensures that nurses, patients, and other healthcare providers work together.

What are the parts of a Care Plan?

Step 1: Assessment

The first step in creating a care plan is to use critical thinking skills to collect data. For the assessment phase, different healthcare organizations use other formats. In general, the information gathered here will be subjective (for example, verbal statements) and objective (for example, height and weight, intake/output). The patients or their caregivers, family members, or friends could be the source of the subjective data.

Nurses can assess patients’ vital signs, physical complaints, observable body problems, medical history, and current neurological functioning. By automatically populating some of this information from previous records, digital health records may aid in the assessment process.

Step 2: Diagnosis

A nursing diagnosis is described as “a clinical assessment reflecting the person’s sensitivity to health illnesses or life processes” by the North American Nursing Diagnosis Association (NANDA).

First, the nurse will make a diagnosis, and the appropriate nursing interventions can be planned and implemented. Maslow’s Hierarchy of Needs (which classifies human requirements) is the foundation for a nursing diagnosis and guides treatment planning. Physiological conditions, for instance, take precedence when it comes to nursing acts since they are more necessary to survival than love and belonging, self-esteem, and self-actualization.

Step 3: Outcomes and Planning

The planning stage follows the diagnosis. You will create smart goals based on evidence-based practice (EBP) guidelines in this section. As you set goals for the patient to achieve desired and realistic long-term and short-term health effects, you will consider their overall condition, as well as their diagnosis and other relevant information. Step 3 entails establishing objectives (in light of the diagnosis) to facilitate nursing treatments that will improve the patient’s condition.

Step 4: Implementation

Once you’ve established goals for the patient, it’s time to put the actions that will help them achieve them. Long-term and short-term health effects As a nurse, you will either carry out doctors’ orders for nursing interventions or create your own using evidence-based practice guidelines.

Family, behavioral, physiological, complex physiological, community, safety, and health system interventions are divided into seven categories. During each shift, you must perform the following basic interventions: pain assessment, changing the resting position, listening, cluster care, fall prevention, and fluid consumption.

Step 5: Evaluation

In the last treatment plan phase, the health professional (a physician or nurse) will determine if the expected result has been achieved. The care plan will change in light of the new facts.

How to Write an Effective Care Plan

We want you to feel a sense of excitement and comfort when creating care plans… and here’s a hint: they’re not going away! Here are the five steps:

  1. Collect Information
  2. Analyze
  3. Think About How
  4. Translate
  5. Transcribe
     

Step 1 – Collect Information

  • Collect information from all sources at once.
  • Your complete evaluation
  • Conversations with patients and family members
  • Observations (lab values, vital signs) (lab values, vital signs)
  • Report (or your report sheet) (or your report sheet)
  • Review of the chart and notes
  • Discussions with members of the healthcare team

Step 2 – Analyze

  • Examine all available data.
  • What are the areas where this patient is having difficulty and needs to progress?
  • Consider how you could see the patient improving and how you would know if they were improving.
  • Make a list of the general issues, how you’d help them progress in that area, and how you’d know if they were making progress.

Step 3 – Think About How

  • Consider how you discovered these problems.
  • What made you think he was in pain? Did he inform you? Did you notice it? Was he getting pain relievers?
  • Examine each “how” to determine whether it is subjective (is this pain or something the patient told you about?) or objective (did you gather this information using your five senses?)
  • Mark them with an S or an O.
  • What could be the connection between these issues?
  • A recent surgery, trauma, or illness?
  • Under the problem(s) you’ve identified, write down all of your reasons (again, in layman’s terms).
  • What would you do to improve this situation? (Interventions)
  • How would you know if things improved? (Evaluation)

 

Step 4 – Translate

  • Bring your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
  • Look up and write down the official terms for the problem(s).
  • Look up outcomes and interventions that might be related to what you wrote down.

Step 5 – Transcribe

  • Prepare your nursing care plan template.
  • Connect the dots (problem + related factor(s) + defining characteristics/”hows”)
  • Make a nursing diagnosis.
  • Place your subjective and objective data using your S’s and O’s.
  • Make a list of your interventions and outcomes/evaluations.
  • Put your feet up; you’re finished!

About From the Heart Home Care, LLC