Nurse practitioners have an important role to play when it comes to assessing and planning effective care to meet their patient’s healthcare needs. Care plans are one of the core parts of nursing as they enable nurses to assess patient needs and ensure resources are properly allocated to meet those needs. As a result, patients enjoy more positive outcomes when they are treated.
A care plan is a great way to streamline and strategically approach the nursing process, along with communicating and collaborating effectively with your nursing team. It can include a range of topics from care planning, advantages of care planning, care pathways, certain models of care and the importance of mental health care during treatment.
Here is a guide to help you create and understand the fundamentals of care planning and how it helps to improve patient care and use resources more effectively and efficiently.
Top reasons to create a care plan
A nursing care plan helps nurse practitioners to identify a patient’s needs. This provides a roadmap to providing patients with holistic care. This is often created according to a five-step framework, which includes collaboration and communication between healthcare providers, nurses, and patients.
Here are some of the main reasons why writing and assessing a care plan is crucial to ensure proper patient care.
1. Patient-centric and value-based care
A patient-centered care plan often involves tailoring a standard care plan. This ensures a more personal and holistic approach to meeting the specific needs and goals of a patient. You can optimize care so that it is best suited to each patient’s unique needs and healthcare goals. A nursing care plan allows nurse practitioners and other members of the care team to organize certain aspects of patient care according to a specific timeline.
There are seven primary dimensions of patient-centered care. Each dimension supports physical, social, psychological and spiritual care. Researchers have found thatPicker’s eight principles of patient-centeredcare practices are conducive to making the care plan creation process easier. This allows patients to get more involved in their treatment and recovery and supports a more positive patient experience.
Individual care plans can help patients feel that their care is tailored to meet their specific needs. This helps them feel more valued and heard. This is essential in today’s healthcare environment, where patient satisfaction is becoming increasingly important.
2. Nursing teamwork and collaboration
A care plan works as a foundation to allow registered nurses, physicians and other healthcare providers to access the same information, collaborate and even share ideas to offer the best possible care for their patients.
This is essential when multidisciplinary teams are working together. A care plan helps to put the patient’s care at the forefront and allows nurses and other healthcare professionals to work together to ensure optimal treatment outcomes.
3. Managing compliance documentation
A well-written care plan allows a nurse practitioner to measure the effectiveness of care and the resources that are used. It also enables them to maintain records of the care that each patient receives. This can help to provide documentation and maximize care efficiency.
Understand the major components of a care plan framework
Here are some of the major elements of a care plan that allow nurses to prioritize patient care and utilize the available resources.
1. Evaluation
The first step of developing a care plan requires data collection and critical thinking skills. Each healthcare organization uses a specific format. This data may include verbal statements from the patient, caretakers, friends or family as well as measurements such as height and weight.
Nurse practitioners can also gather data about the patient’s medical history, physical complaints, current neurological functioning, and vital signs. This, along with digital health records, can help them better assess information regarding their patients.
2. Analysis
Using the data collected, you can then come to a certain conclusion or judgment regarding your patient’s health conditions. What risks they are exposed to, and how to determine a diagnosis.
This allows you to choose nursing actions to achieve a specific outcome. For example, if your patient shows symptoms that stem from a lack of proper food or water, this allows you to prioritize physiological needs such as food, water, and sleep. When it comes to nursing actions, build your care plan around this diagnosis.
3. Building an outcome plan
Once a diagnosis has been reached and you are at the treatment planning stage, you can then create evidence-based goals. This is done by considering the patient’s overall condition, along with any other information and their diagnosis.
This will assist you in setting goals to help them achieve their desired results and realistic health outcomes for both the long and short term.
4. Execution
After setting goals with the patient, you will need to support your patient and ensure that they achieve these goals. As a nurse practitioner, you will either follow the outlined care plan provided by the patient’s doctor or develop one yourself using evidence-based care plans. This will include several components such as family behavior, complex physiology, safety, health systems, and community.
Each basic intervention needs to be followed by the nurse practitioner during each shift. This includes pain assessment, monitoring fluid consumption, listening, changing the patient’s position and meeting added safety requirements.
5. Estimation
As the final step of the care plan, you need to understand that most patients often allow their mental health to take a backseat. This can lead to stress and anxiety. Mental wellness is extremely essential in your health care plan.
You need to take steps to focus on yourpatient’s mental health, beginning with listening to them, having the correct attitude and even getting them to talk to a therapist. You can then adjust the care plan based on this information.
Core principles for creating your care plan
When it comes to creating your care plan, as a nurse practitioner, you need to ask yourself what your patient is suffering from, both now or in the long term. Why does your patient suffer from this ailment, and how can you make this journey more comfortable for them?
If you already have anADN or ASN and are a registered nurse, you can enhance your knowledge about care plans with the help of the uniquely designed master’s degree programs. Alternatively, if you are keen to pursue nursing as a career, there are CCNE-accredited BSN programs that will also help you acquire clinical expertise to not only assess patients but also learn about care plans to help in the treatment and management of diseases.
Equipped with the right education, knowledge and expertise, you will appreciate the importance of nursing care plans and how patient-centric interventions help in improving treatment outcomes.
It is important that you use goal-oriented strategies such as critical thinking, nursing intuition, evidence-based practices and patient-centered techniques to help you through this process.
Maintaining effective communication
Unless your care plan is communicated effectively to all physicians, healthcare providers and the patient’s family or caregiver, it will only remain at a plan level. A nursing care plan is not just documentation, it also provides effective guidelines.
This can help guide the patient’s care and enable teamwork to help improve the patient’s wellbeing. As a nurse practitioner, you need to be as current and accurate as possible in your care plan and focus on effective communication skills.
Note down everything immediately so that you don’t forget about it. Write clearly and precisely so that others can easily understand, this should include dates and times. While communication skills are often gained during schooling, you will also develop them over time in the field.
Convenient and easy to access
Once you have prepared your care plan, keep in mind that your plan needs to be easily shareable with patients, physicians, insurance companies, and other members of the nursing team. Ensure that your document is in line with all the hospital rules and policies, and is created in a format that is easily accessible to everyone.
Include the latest information
Lastly, you will need to update your care plans regularly. This ensures they stay in line with the current technology, latest symptoms, and information. This means keeping up to date with current news and insights, recording data about how the patient is progressing towards their goals, and more. This can help you maintain your nursing plan.
A care plan is an essential part of nursing
As a registered nurse, a nursing plan needs to meet certain criteria. This may include effective communication, critical thinking, goal-oriented tasks, accessibility, and a general focus on the patient. A nursing care plan, if created properly, becomes a go-to resource for nurses to record and access all the information they require during the treatment and patient care process.
Care plans help to ensure that available resources are used effectively, so that you can improve treatment outcomes.
