I am currently teaching some science subjects in the College of Nursing (Anatomy and Physiology, Health Ethics and Science Technology and Society). This exposed me to some of the reports and projects of the student nurses. One particular paper requirement that I am taking interest in is the Nursing Care Plan.
Why? The nursing care plan is often seen (and misunderstood) by most student nurses and registered nurses as too cumbersome and often a waste of time. Also because of its name (nursing care plan), it is often thought to be relevant only to nursing. We have to remember that caring for the patient is an essential part of healthcare. Therefore planning for such care is equally important and very much essential to the effective delivery. The nursing care plan or more popularly known to students as NCP, is a “map” or written guideline to ensure that all issues of the plan of care are not neglected. This provides a comprehensive plan not just for the nurse but also for other people involved in the care of the patient. This includes the family members, other nurses, and even the patient himself/herself.
The NCP has 7 steps/ parts namely assessment, nursing diagnosis, analysis, objective, nursing intervention, rationale, and evaluation.
Assessment as an initial step should be accurate and comprehensive otherwise the plan will be useless. Assessment includes a restatement of the verbalization of the patient to determine the patient's exact status and complaints.
After completing the initial assessment, a problem list should be prepared. This could be as simple as a list of nursing/ medical diagnoses.
Once the problem list is completed, look at each problem, analyze and ask the question, “What could be the probable cause of the problem?”, "Will this problem get better?" (Or, "Can we make this problem better?") If the answer is yes, then your goal will be for the problem to resolve or show signs of improvement within the review period. In the acute setting, the review period may be as short as next shift, next day or next week. In the long-term or home health setting, the review period will likely be longer.
In any case, the goal should be specific, measurable and attainable. Do not write a goal that a stroke patient’s heart muscle strength "will be improved by next week." This is not specific or measurable, and most likely not attainable. A better goal statement would be for "stroke patient” to improve and recover by exhibiting increased activity in the next 90 days." The approaches (or interventions) should also be measurable and realistic, and should be documented elsewhere in the record when performed.
The rationale explains in detail why such nursing intervention is needed. The evaluation phase includes the accomplishment of the goals that were set.
The nursing care planning process is never truly completed until the patient/resident is discharged from the current care setting or is deceased. The care plan needs to be fluid and changeable, as patient/resident status changes. Periodic scheduled reevaluation must take place, with changes being made as needed. Unscheduled updates should also be made as condition warrants. When a problem has resolved, that problem can be completed. If the person has had a major change in a problem area that results in changes in goals and approaches, it may be easiest to resolve the problem and enter an entirely new problem, goal(s) and approaches, rather than making many changes to the existing problem.
Remember that the ultimate purpose of the nursing care plan is to guide all who are involved in the care of this person to provide the appropriate treatment in order to ensure the optimal outcome during his/her stay in our healthcare setting. A caregiver unfamiliar with the patient/resident should be able to find all the information needed to care for this person in the nursing care plan.
Watch out for my next post: Sample NCPs
