Nursing Care Plans

Much like an instruction manual, nursing care plans dictate the exact kind of care that must be provided to a sick or recovering individual. Additionally, these plans can be expanded to include care that must be given to families or entire communities. These plans are devised after careful scrutiny of the affected person(s) condition, and are a crucial part of the nursing process.
Nursing care plans are highly detailed documents which are drafted for every individual on a case-by-case basis. This makes each care plan specific to the receiver of the care. Creating an effective care plan also requires a lot of effort and careful analysis of data. The nurse must look through the patient’s complete medical records for his time in the hospital, paying close attention to any irregular values that show up in vital signs or otherwise. This is the first step in creating a particular nursing plan.

The next step is to communicate with the patient to gather more information about the condition. This data will be considered subjective since it is being obtained from the patient themselves. Conducting simple physical tests and assessing pain levels can offer insight which is helpful in forming a diagnosis. Developing the diagnosis requires you to match the objective and subjective symptoms to the approved North American Nursing Diagnostic Association’s manual.
Once a diagnosis has been formed, the next step is to work closely with the patient to identify long and short term goals with regards to recovery. Whether this includes physiotherapy, or simply prescribing particular medication and noting changes in health, they will have to be included. Working with the patient in this scenario is recommended since you can develop nursing care plans which both the patient and the nursing staff are comfortable with and neither is overly taxed.
A nursing care plan for pain, for instance, will require the nurse to look over the physician’s notes and prescribed treatment to identify potential causes. Coupling this with information gathered from the patient, a plausible diagnosis can be determined. Following this, the nurse will have to develop a particular care strategy to help the patient. In the short term, this could simply mean prescribing painkillers or sedatives to alleviate the pain. In the long term, this could involve massage, physiotherapy, or even surgery to correct the condition.
With each potential therapeutic suggestion, the nurse is required to provide a rationale for the choice. This is in order to ensure that the treatment is well thought out and not haphazardly recommended. There is also a need to justify the choice of diagnosis that a nurse makes based on the objective and subjective symptoms of the individual, to show a clear match between the symptoms and condition.
Nursing care plans are important because they follow a standard format that all nursing staff can understand. If a patient transfers between hospitals, the care plan can help the new nursing staff continue providing the same quality of care to the patient based on the instructions within the plan.