Nursing care plans play a vital role in everyday medical care,
helping to ensure that the individual needs of each patient are met
consistently. Medical care requires the cooperation of a variety of
professionals and paraprofessionals, each of them needing an accurate
assessment of the patient to perform their function effectively.
Comprehensive care planning is essential to the process, keeping the
myriad of important details about the care of each patient organized
and accessible to the health care team.
To meet the needs of
a patient, a complete clinical overview of the health status and
history is necessary. This process of assessment and documentation of
overall patient condition is generally the first step in any nursing
care plan. A proper assessment should include both objective and
subjective data. Objective data includes a physical examination,
documenting vital signs, direct observation, and chart information like
lab tests and their results. Subjective data records details such as
patient complaints, prognosis and disease process, health care needs,
and patient abilities or disabilities.
The next step in a
comprehensive nursing care plan generally deals with the nursing
diagnosis, documenting the health issues of a patient according to
priority. Major issues, requiring the most intensive nursing care, are
listed first, with all others listed in descending order of severity
and concern. Input from the patient or family is important to this
section of the nursing care plan.
Treatment and recovery
goals are the next item to be addressed in most nursing care plans.
This section details the method of treatment or care to be used for
each health care issue that needs attention, the outcome that is
anticipated, and the time frame in which these goals are expected to be
met. Both short and long term plans ought to be included.
The
development of an accurate and comprehensive nursing care plan is a
process that is often underestimated, seen as just more paperwork,
wasting time that could be better spent on direct patient care.
However, the details included in the nursing care plan are crucial to
ensure that vital patient information is available to all members of
the health care team, helping to maintain smooth and coordinated care
for the best possible outcome.