Nursing care plan development and implementation

Nursing Care Planning

Background- In contemporary nursing an issue comprising three essential attributes, respect for patient value & individuality, education of patients, and cognition and respect for the realities of contemporary medicine becomes the template for patient care planning. During the diagnosis and initial opinion period, there are several events that will necessitate the nurse acting on behalf of the patient because of the patient's inability to either act or understand the procedure. (Burkhard, et.al., 2007). Thus, the nurses' role as an advocate is to facilitate, encourage or to enable patients to be involved in all aspects of their healthcare, and when unable to do so, act in their stead. The modern nurse's role is not limited only to assist the doctor in procedures, however. Instead, the contemporary nursing professional takes on a partnership role with both the doctor and patient as advocate caregiver, teacher, researcher, counselor, and case manager. Under the paradigm of quality health care, modern nurses should interpret this as "quality patient care" -- which comprises three important factors -- sound theoretical knowledge of the latest medical procedures, information and innovations; superior communication skills that are multi-culturally based; and the ability to empathize appropriately with the patient and family to buttress the role of caregiver. The necessity for modern nurses is to be far more than ever -- more of a multitasking professional with superior communication and organization skills -- and even more focused on the holistic model of the patient and the manner in which they, the nurse, affects the outcome of the patient's care experience (Brown, 2007). One of the major tools nurses use to adapt these various skills and responsibilities to individual patients is the nursing care plan.

The Nursing Care Plan- A typical nursing care plan outlines the actions, medications, and medical plans that the nurse will use to provide appropriate patient care. It is an intermediate stage of the nursing process, and focuses on guiding the ongoing and fluid process of nursing care and evaluation. The idea nursing care plan has six major parts: 1) It focuses on actions which are designed to solve or minimize the existing problem; 2) It is a product of a deliberate systematic process; 3) It relates to the future; 4) It is based upon identifiable health and nursing problems; 5) Its focus is holistic, and 6) It focuses to meet all the needs of the service user (Barrett, et.al., 2009). Essentially, the plan allows a nurse to individualize appropriate care procedures that prevent overlap, omissions, and allow the nurse to assume the hub role of care when there are multiple physicians involved (Doenges, et.al. 2002). The plans have one primary purpose, though. That is to provide cogent and appropriate directions for the nursing staff surrounding an individual's care. To accomplish this, there are essentially 10 steps to the care plan:

Step/Name

Overview

Identify Strengths

Identify Risks

Assessment

Assessment form used by individual facility

Helps identify items that aid to healing outcomes

Identify risk factors or individual characteristics that can hinder healing

Emergency Assessment

In emergency or pre-operation, use basic form

What is client able to do? Likely able to do after procedure?

What are the conditions making client more vulnerable?

Initial Care Plan

The quick overview plan

Find overall issues, why is client hospitalized?

Identify potential risks

Identify Additional Concerns

More specificity

Options?

Potential complications or serious risk factors

Review Standard Plan

Review each section

Verify as appropriate

Verify as appropriate

Review Nursing Diagnosis

Review Diagnosis

How does plan apply to individual client?

Is there anything on the plan that would make symptoms or diagnosis worse?

Prepare Care Plan

Typed or written, most organizations have software template

If no risked factors, the done

If heightened risk factors, identify and recommend.

Complete Care Plan

Associated care plan completed

None -- done

Additional research, collaboration, consultation.

Additional Risk Factors

Very specific evaluation

Collaborative or nursing issues that are important but may, by necessity, be delayed

Priority identification -- anticipate problem prior to formalizing plan

Review, Revise, Assess

Fluid and continuous

Depending on treatment outcome

Surgery or treatment may accentuate

(Carpenito-Moyet, 2009, 25-31)