Uses of Nursing-Care Plans

Nursing-care plans are an important part of the nursing process. They allow nurses to diagnose health problems and threats, create goals to avoid or overcome those problems, and interventions to meet the goals. Care plans become part of the patient's chart, which allows every nurse, doctor and specialist involved in the patient's case to more easily monitor progress and potential risks to the patient's health. Care plans are re-evaluated and updated throughout the patient's stay at the facility.

The Nursing Process

• The nursing process begins at the first meeting with the patient. Nurses conduct patient interviews detailing past medical history and current health status. They gather information from all available sources and evaluate the data. Once they have a full picture of the patient, they formulate actual and risk diagnoses and plan goals and interventions to achieve the best possible outcome. The interventions are implemented through a care plan and evaluated regularly to determine if the interventions are working or the goals need to be updated.

Importance of Nursing Diagnoses

• Nursing diagnoses differ from those of a doctor because they determine potential health problems rather than diagnosing a particular disease. Where a doctor may diagnose a patient with a staph infection and order antibiotics, a nurse looks at the wound and sees a risk for impaired skin integrity, which can lead to bedsores. The list of approved nursing diagnoses is set forth by the North American Nursing Diagnosis Association (NANDA), although some hospitals allow nurses to create their own diagnoses. Nursing diagnoses allow nurses to care for the entire patient rather than just the disease.

Types of Care Plans

• Short-term nursing care plans are used in hospitals and facilities where the patient will only be present for the duration of the illness. These care plans focus on treating and preventing complications of the illness and educating the patient about self-care after he leaves the hospital. Long-term care plans are often found in nursing homes or other facilities where the patient is expected to spend months or years under medical care. These plans are constantly adapted to allow for changes in the patient's physical and mental status.

Whole-Body Approach

• Care plans are designed to treat not only the physical problems and risks but also the emotional well-being of the patient and her caretakers. Nurses look for signs of emotional disturbances, including low self-esteem and caregiver role strain, and incorporate these issues into a care plan. Care plans also include plans for patients who are ready to take a more active role in managing their care with NANDA-approved diagnoses such as "readiness for enhanced management of therapeutic regimen" and "readiness for enhanced communication."

Example

• An example of a nursing-care plan entry for a patient with potential emotional issues caused by treatment setbacks may begin with a diagnosis of "risk for situational low self-esteem related to unrealistic self-expectations." A possible goal may be to have the patient identify strengths and healthy coping skills before leaving the hospital. The interventions may include helping the patient identify the current behaviors leading to low self-esteem and encouraging the client to perform as much self-care as he is capable.