A nursing care plan (NCP) is a written document that outlines the nursing care to be provided to a patient. It is a systematic and individualized approach to nursing care that serves as a guide for nurses in delivering patient-centered care. The care plan is developed by a registered nurse (RN) or other healthcare professionals, in collaboration with the patient, their family, and the healthcare team.
Review: Nursing Care Plans Writing Guide:
Key Components of a Nursing Care Plan (NCP)
A Nursing Care Plan (NCP) typically applies the ADPIE format. The ADPIE format, which stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation, is commonly used to guide the development and documentation of nursing care plans.
A nursing care plan (NCP) typically includes the following components:
- Assessment: A comprehensive assessment of the patient’s physical, emotional, psychological, and social well-being. This includes gathering information about the patient’s medical history, current health status, and any specific nursing diagnoses.
- Nursing diagnoses: Identification and documentation of nursing diagnoses based on the assessment findings. Nursing diagnoses are clinical judgments about the patient’s response to actual or potential health problems.
- Goals and outcomes: Development of measurable goals and expected outcomes that are realistic and achievable. Goals should be specific, measurable, attainable, relevant, and time-bound (SMART goals).
- Interventions: Planning and implementation of nursing interventions to address the identified nursing diagnoses and achieve the desired outcomes. Interventions may include direct patient care, health education, medication administration, coordination of care, and collaboration with other healthcare professionals.
- Evaluation: Regular assessment and evaluation of the patient’s progress towards the established goals and outcomes. The care plan should be continually reviewed and modified as needed to ensure the patient receives appropriate and effective care.
- By utilizing a nursing care plan, healthcare professionals can ensure continuity of care, improve patient outcomes, promote patient involvement in their own care, and facilitate effective communication among the healthcare team.
- The ADPIE format provides a systematic and organized approach to developing, implementing, and evaluating nursing care plans. It helps ensure continuity of care, effective communication among healthcare providers, and the provision of individualized and evidence-based nursing care.
Types of Nursing Care Plans Based on Specific Needs and Conditions of Patients
There are various types of nursing care plans that can be utilized based on the specific needs and conditions of patients. Some common types include:
- Standard/Basic Care Plans: These are general care plans that address common nursing diagnoses and interventions for patients with typical healthcare needs. They serve as a foundation for providing routine care and are often used in settings like hospitals, clinics, and long-term care facilities.
- Concept Map Care Plans: Concept mapping is a visual representation of the relationships between patient problems (nursing diagnoses), interventions, and outcomes. Concept maps help nurses and other healthcare professionals identify patterns, connections, and priorities in the patient’s care.
- Critical Pathway Care Plans: Critical pathways, also known as care pathways or clinical pathways, are standardized plans that outline the sequence and timing of interventions for specific medical conditions or procedures. They are designed to promote efficient and cost-effective care by providing a structured approach to patient management.
- Discharge Care Plans: These care plans focus on the needs of patients who are preparing for discharge from a healthcare facility. They include information on post-discharge instructions, medications, follow-up appointments, and self-care measures to ensure a smooth transition to home or another care setting.
- Collaborative Care Plans: In complex cases involving multiple healthcare providers, collaborative care plans are developed. These plans involve interdisciplinary teamwork, where nurses, physicians, therapists, and other professionals collaborate to address the patient’s needs comprehensively and ensure coordinated care.
- Problem-Oriented Care Plans: Problem-oriented care plans are structured around specific healthcare problems or diagnoses identified during the assessment. Each problem is addressed individually, with corresponding goals, interventions, and evaluation methods.
- Patient-Specific Care Plans: These plans are tailored to meet the unique needs of individual patients. They take into account the patient’s specific health conditions, preferences, cultural background, and other factors that influence their care. Patient-specific care plans promote personalized care and patient-centered decision-making.
- It’s important to note that these types of care plans are not mutually exclusive, and elements from different types can be combined or adapted based on the patient’s requirements.
- The choice of care plan type depends on the clinical setting, patient population, and the complexity of the patient’s condition.
NCPs Presentation Techniques: 3-column, 4-column, and 5-column Formats
The 3-column, 4-column, and 5-column formats are different variations of organizing nursing care plans (NCPs) to facilitate the documentation of nursing diagnoses, interventions, and outcomes. Here’s a brief overview of each format:
A. 3-Column Nursing Care Plan Format:
The 3-column format is a simplified approach that includes three columns to document the nursing diagnosis, desired outcomes, and nursing interventions. It is a concise format that allows for quick and straightforward documentation.
3-Column NCP Example
Here’s an example of a tabular presentation of the 3-column format for a nursing care plan:
| Nursing Diagnosis | Desired Outcomes | Nursing Interventions |
|---|---|---|
| Impaired Mobility | – Patient will demonstrate improved mobility within 48 hours.
– Patient will be able to ambulate independently with the use of assistive devices. |
– Assess the patient’s mobility status, including strength, range of motion, and balance.
– Encourage and assist the patient with safe ambulation and transfers. – Teach the patient proper use of assistive devices. – Collaborate with physical therapy for exercises and gait training. |
- In this example, the nursing diagnosis is “Impaired Mobility.” The desired outcomes include the patient demonstrating improved mobility within 48 hours and being able to ambulate independently with the use of assistive devices. The nursing interventions listed include assessing the patient’s mobility status, assisting with ambulation and transfers, providing education on assistive devices, and collaborating with physical therapy for exercises and gait training.
- Please note that this is a simplified example, and in a real nursing care plan, there may be multiple nursing diagnoses, corresponding outcomes, and interventions documented in separate rows or sections of the table.
B. 4-Column Nursing Care Plan Format:
The 4-column format expands on the 3-column format by including an additional column for evaluation related to the nursing diagnosis alongside the nursing diagnosis, outcomes, and interventions.
4-Column NCP Example
Here’s an example of a tabular presentation of the 4-column format for a nursing care plan:
| Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Evaluation |
|---|---|---|---|
| Impaired Mobility | – Patient will demonstrate improved mobility within 48 hours.
– Patient will be able to ambulate independently with the use of assistive devices. |
– Assess the patient’s mobility status, including strength, range of motion, and balance.
– Encourage and assist the patient with safe ambulation and transfers. – Teach the patient proper use of assistive devices. – Collaborate with physical therapy for exercises and gait training. |
– After 48 hours, patient’s mobility has improved. Patient is able to ambulate independently with a walker and perform transfers safely. |
- In this updated example, the nursing diagnosis is “Impaired Mobility.” The desired outcomes remain the same. The nursing interventions listed are also unchanged, including assessing the patient’s mobility status, providing assistance and education, and collaborating with physical therapy. The addition in this format is the evaluation column, which documents the assessment of the patient’s response to the interventions. In this case, the evaluation indicates that after 48 hours, the patient’s mobility has improved, and they are able to ambulate independently with a walker and perform transfers safely.
- Again, please note that this is a simplified example, and in a real nursing care plan, there may be multiple rows or sections in the table to document different nursing diagnoses, outcomes, and interventions.
C. 5-Column Nursing Care Plan (NCP) Format:
The 5-column format adds an additional column to the 4-column format, allowing for more detailed documentation of the rationale or scientific justification for the selected nursing interventions.
5-Column NCP Example
Here’s an example of a tabular presentation of the 5-column format for a nursing care plan:
| Assessment Data | Nursing Diagnosis | Desired Outcomes | Nursing Interventions | Rationale |
|---|---|---|---|---|
| Subjective: Patient reports pain level of 8/10.
Objective: Guarding behavior, facial grimacing, vital signs within normal limits. |
Acute Pain related to surgical incision. | – Patient will report pain level decreased to 4/10 within 24 hours.
– Patient will demonstrate use of pain management techniques effectively. |
– Administer prescribed pain medications as ordered.
– Provide comfort measures such as positioning, warm compresses, or relaxation techniques. – Educate patient on non-pharmacological pain management strategies. |
– Providing pain medications helps alleviate discomfort and manage pain.
– Comfort measures and non-pharmacological techniques promote relaxation and pain relief. – Patient education empowers the patient to participate in pain management. |
- In this example, the assessment data includes subjective information (patient reports pain level) and objective data (guarding behavior, facial grimacing, normal vital signs). The nursing diagnosis identified is “Acute Pain related to surgical incision.” The desired outcomes are for the patient to report a decreased pain level within 24 hours and demonstrate the effective use of pain management techniques. The nursing interventions listed include administering prescribed pain medications, providing comfort measures, and educating the patient on non-pharmacological pain management strategies. The rationale column provides the reasoning behind the selected interventions and their expected impact on pain management.
- Again, please note that this is a simplified example, and in a real nursing care plan, there may be multiple rows or sections in the table to document different nursing diagnoses, outcomes, interventions, and their respective rationales.
- These different column formats provide flexibility in documenting NCPs, allowing nurses to choose the format that best suits their documentation needs and the specific requirements of their healthcare setting.