According to Statista, approximately 600,000 patients are admitted to hospitals across the US each day for various illnesses. Every patient is unique, and nursing care plans serve as a roadmap outlining the specific interventions and actions required to meet their individual healthcare needs and facilitate their recovery. Besides, where multiple healthcare providers are involved in a patient’s treatment, care plans ensure everyone is on the same page, working harmoniously towards shared goals.
A nursing care plan is a formal process that identifies a patient’s needs and facilitates holistic care for the best clinical outcomes. A care plan facilitates collaboration among nurses, patients, and other healthcare providers by documenting individual patients’ needs and wants, and the required nursing interventions.
Care plans are divided into the following two types:
Standardized care plans are guides developed by nursing staff and healthcare providers. They primarily target patients with specific conditions to ensure they receive consistent care for the best outcomes. Generally, standardized care plans are designed to ensure minimally acceptable criteria are met. They remove a need to develop everyday routine activities, thus ensuring a nurse’s time is used productively. In a nutshell, standardized care plans are not tailored to a specific patient’s needs and goals. They generally serve as a launching pad for developing an individualized care plan.
As the name suggests, an individualized care plan is a tailored care plan that meets an individual client’s specific needs and goals and leverages specific approaches proven to be effective for that specific client. The approach relies on personalized and holistic care best suited to the patient’s unique challenges, needs, strengths, and goals. Studies have revealed that individualized care plans enhance patient satisfaction. When patients know their care is tailored to their unique needs, they feel heard and valued. This can be crucial in the current healthcare environment, where patient satisfaction is used as a yardstick for measuring quality in various healthcare settings.
Defines a nurse’s role
Care plans are crucial in defining a nurse’s role in the healthcare setting. Care plans guide nursing teams in providing consistent, efficient, and effective patient care without relying entirely on a physician’s orders or interventions. It allows nurses to carry out the interventions outlined in the care plan, including administering medications, providing wound care, and assisting with activities of daily living (ADLs), thus ensuring timely and ongoing interventions for the best outcomes.
A patient care plan may serve as a roadmap for the care that the healthcare team will provide to the patient. They help nurses and doctors tailor interventions considering patient preferences and unique requirements. The interventions may include medication management, therapies, lifestyle modifications, and other appropriate measures.
Generally, the nursing practice makes use of hourly shifts in their workforce. A tailored care plan provides crucial data, allowing nurses from different shifts or departments to provide the same quality and type of interventions to patients. This ultimately ensures clients receive the same quality and continuous care throughout their hospital stay.
A nursing care plan ensures all healthcare team members are on the same page regarding a patient’s care needs and the specific actions that must be taken for those needs to be met. It provides a structured approach to patient care, facilitates communication among healthcare providers, and ensures a coordinated effort to meet the patient’s needs holistically. This way, gaps in care are prevented while optimizing the patient’s healthcare journey.
If nursing care is not appropriately documented in a health facility, there will be no evidence that specific care was provided. Accurate documentation outlines the specific observations that were made, the nursing actions that were carried out, and the instructions that were given to the client or family members. Remember, proper documentation is essential to meet legal and ethical requirements. Accurate and timely documentation ensures that caregivers and healthcare organizations comply with regulations, providing evidence of the care delivered and protecting the rights and well-being of the individual.
Care plans involve patients in their own healthcare decisions and empower them to take an active role in managing their health. They often incorporate self-care strategies such as dietary changes, exercise routines, or symptom management techniques, while providing tools to help them engage actively in their daily routine for better healthcare outcomes. This engagement fosters a sense of ownership and responsibility for their well-being, leading to better compliance with treatment recommendations.
Care plans are generally structured into a five-step framework:
The first step to developing a care plan involves data collection. The data that healthcare professionals collect include both subjective or verbal statements and objective statements such as height, weight, intake, and output. Generally, the source of the subjective data is the patients themselves, family members, friends, or caregivers. Nurses will collect objective data regarding a patient’s vital signs, visible body conditions, physical complaints, current neurological functioning, and medical history.
The nursing team will use the collected data to create a nursing diagnosis. The nursing diagnosis provides a framework for choosing specific nursing actions that help healthcare providers and patients achieve specific outcomes.
Outcomes and planning
Once the diagnosis is developed, nurses will set goals to resolve the patient’s problems. The goals you set should adhere to evidence-based practice (EBP) guidelines. This requires nurses to consider the patient’s overall condition, diagnosis, and other relevant data, which can help them set realistic goals and achieve desired health outcomes.
Once nurses have set goals for patients, they will then implement the actions that support them in achieving those goals. Generally, the implementation stage involves performing the specific nursing interventions outlined in the care plan. Nurses can either follow a doctor’s orders regarding the nursing interventions or develop them themselves using the EBP practices. Implementation is broadly categorized into several domains, including family, behavioral, physiological, community safety, and health system interventions.
In the last step of a care plan, a healthcare professional such as a nurse or doctor evaluates the plan to determine whether the desired outcome was achieved. You will adjust or maintain the care plan based on the evaluation.
During the planning stage of care plan development, one must use goal-oriented strategies. In a nutshell, nurses must ensure they incorporate SMART goals into their care plans:
- Specific: The goals set must be well-defined, clear, and unambiguous.
- Measurable: It’s vital to have specific metrics in place to help measure the patient’s progress toward these goals over time.
- Achievable: The goals set for the patient should be attainable.
- Realistic: The goals should also be within reach and relevant to the overall care plan.
- Time-bound: Ensure the patient’s goals have clear start and end times.
Care plans should be individualized and based on a patient’s current health status and capabilities. This helps healthcare professionals develop treatment strategies that align with patients’ preferences, beliefs, and lifestyles. Personalizing the care plan can also increase the patient’s likelihood of following the plan and adhering to prescribed treatments. Besides, individualized care plans ensure flexibility, allowing healthcare providers to respond to improvements and setbacks effectively.
It is vital that nurses communicate their care plans effectively to all the relevant stakeholders. This way, their plan will effectively guide the entire nursing process while enabling greater teamwork. It is important that nurses communicate clearly, and concisely using terms their teams will understand and include dates and times for specific actions.
The ideal care plans are also easy to share with relevant stakeholders, including patients, doctors, nursing teams, and insurance companies. Although the documentation format may vary from one hospital to another, care plans are generally created via an electronic format that integrates with the electronic health record (EHR) to ensure ease of access by relevant stakeholders.
The medical world transforms rapidly with new research, interventions, and treatments unveiled daily. Besides, as time passes, more information about the individual’s health history, preferences, and responses to treatments may become available. Integrating this new information into care plans can lead to better-informed decisions and personalized care. Updating care plans allows healthcare professionals to determine whether the current treatment strategies are working or if modifications are necessary.
The field of healthcare is constantly evolving with new medical breakthroughs, treatment modalities, and technological advancements. This is why nursing care teams require ongoing training to ensure they are informed about the latest developments and are equipped to use the most up-to-date techniques and tools in the provision of quality care.
By enrolling in FNP programs online, nurses gain relevant skills to help them meet the challenges of their roles in a dynamic healthcare environment. The online FNP programs at Marymount University offer a transformative path for nurses seeking personal and professional growth. Such courses equip students to deliver holistic care to patients of all ages throughout their lifespans and open doors to diverse opportunities in their nursing careers.
Different organizations have their own care plan layouts with different sections designed to help them deliver the best care possible. However, regardless of the format, ideal care plans are usually person-centered. They are tailored to the person, using the language they understand while focusing on their priorities and goals. Care plans should include primary information on a patient, such as their specific needs and desired outcomes, and factors such as culture, ethnicity, gender, sexuality, and any disabilities they may have. The plan should also include the type of support a patient needs, the professionals who will provide care, the time and place where the care will be provided, care records, acknowledgment of any disagreements and differences, details of relevant family members, any necessary home adaptations, and the costs of services provided.
Now more than ever, innovative technologies are finding ways to impact the healthcare industry. A survey of 600 professional nurses revealed that 82% agree that new technology and equipment innovation help enhance patient care. Technology plays a crucial role in nursing care planning by empowering nurses with the tools and information they need to deliver safe, efficient, and patient-centered care.
Decision support systems
These systems use data and algorithms to assist nurses in making evidence-based decisions. They analyze patient data and medical literature to provide relevant information, alerts, and recommendations. This helps nurses identify potential risks and choose the most appropriate interventions for each patient.
Portable monitor equipment allows nurses to check on patients anytime and anywhere, even when they are on the move or busy with other duties. Portable devices monitor vital signs such as respiratory rates and blood pressure while transmitting the information back to the central monitor. The nursing care team will be notified promptly whenever there is an emergency.
Smart beds leverage innovative technologies to track movement, weight, and vitals. They also play an integral role in keeping patients comfortable and safe during extended hospital stays. Additionally, smart beds enable nurses to achieve a constant in-room monitor by providing regular updates and communication on a patient’s activities.
Wearable devices and mobile apps are revolutionizing the care planning industry. Devices that track heart rates, sleep, respiration, and exercise are helping clients take charge of their own health. With the increased use of technology, nurses are also turning to apps and devices to provide personalized care for patients. For example, a stethoscope app allows nurses and doctors to use their smartphones to get breathing sounds and monitor heart rates. Wearable devices eliminate the risk of human error for nurses since the communication of data is generated directly from the device itself.
Electronic health records (EHR)
EHR has replaced older paper filing methods in healthcare settings. The technology enables nurses to document care provided to patients and access crucial information that helps personalize care. Besides, the information entered in data systems can be accessed easily by care teams, including doctors and patients, whenever needed.
Telehealth and telemedicine
Telehealth platforms enable nurses to conduct virtual consultations with patients, assess their conditions remotely, and provide ongoing support. Telemedicine can be particularly useful in care planning for patients with limited access to healthcare facilities or requiring frequent follow-ups.
Care plans enhance patient recovery by providing a structured and personalized approach to patient care. They consider the patient’s medical history, current health status, and any unique circumstances that may impact their recovery. Care plans also provide a roadmap for healthcare providers, families, and patients to follow, leading to better outcomes and improved overall well-being.