In this lesson, you will learn the reasoning behind creating a nursing care plan. We will look at nursing care plan use during nursing school and clinical practice.

With successful completion of this lesson, you will:

1. Know what a nursing care plan is
2. Understand the reason nursing care plans are assigned in nursing school
3. Understand nursing plans use in clinical settings
4. Understand the nurse’s role in patient care planning
5. Know the purpose of nursing care plans
6. Champion the benefits of using a nursing care plan

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What is a Nursing Care Plan?

A Nursing Care Plan is the way a nurse documents and communicates the Nursing Process.

Nursing care plans are one of the most common assignments in nursing school and can be a valuable resource in the clinical setting. They start when a patient is admitted and document all activities and changes in the patient’s condition. Using a care plan will encourage patient-centered care and make your nursing care more consistent. These plans are also a great communication tool among nurses, other healthcare professionals, patients, and their families.

Nursing students learn to assess a patient, make a nursing diagnosis, create a plan, implement the plan, and evaluate the plan to ensure best practices and outcomes. This process teaches them to problem-solve and make critical decisions. A nursing care plan helps nurses organize their day, know when things need to be accomplished, and balance their workload.

Nursing Care Plans in School

Nursing care plans are used to teach nursing students how to work through the nursing process, think critically, and provide patient-centered care. By writing things down, nursing students learn the basics of patient care and the building blocks for providing quality care.

Teach Critical Thinking

Critical thinking skills are an essential part of a nurse’s career. Writing out care plans help student nurses develop their critical thinking skills by making them think through each step of the nursing process and document it clearly.

When writing a nursing care plan, it is good to remember the seven basic skills of critical thinking:

• Observation
• Analysis
• Interpretation
• Reflection
• Evaluation
• Inference
• Explanation
• Problem-solving
• Decision making

Ensure Patient-Centered

Nursing care plans are key to providing patient-centered care and treatment. These plans assist nurses in providing individualized care and gaining a complete picture of a patient’s health.

Care plans outline the patient’s short- and long-term needs, recovery goals, and coordination requirements. They identify who is responsible for each part of the plan and can be used as a communication tool with medical staff, the patient, family members, and community or social services.

Nursing Care Plans in Clinical Practice

Care plans are used to teach nursing students how to individualize patient care, think critically, and learn the nursing process. Experienced nurses typically do this without documenting it. A formal nursing care plan can be a valuable tool for effective communication, and many healthcare facilities are beginning to utilize them formally.

Purpose of Nursing Care Plans

Nursing Care Plans are a written form of The Nursing Process. These plans ensure nurses deliver consistent, patient-centered, and holistic care. Each step in the nursing process is covered in the nursing care plan and helps nurses plan, implement, and evaluate nursing care.

The fives steps in the nursing process are:

1. Assessment: The first step in delivering nursing care. It collects and analyzes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors data. A good assessment allows you to identify:
   1. Priorities
   2. Your patient’s biggest problem
   3. What needs to be addressed today
2. Diagnosis: Using the data, patient feedback, and clinical judgment to form the nursing diagnoses. The diagnosis considers the patient’s signs, symptoms, pain, and the problems their condition has caused, such as anxiety, poor nutrition, conflict with family, and complications that may arise. The nursing diagnosis is the basis for the care plan. A good diagnosis should:
   1. Be contain patient-centered, holistic interventions
   2. Focus on the patient
   3. Uncover the patient needs
3. Planning: Setting short-term and long-term goals based on the nurse’s assessment and diagnosis.  Ideally, with input from the patient. This is where you determine nursing interventions to meet these goals. A good plan should:
   1. Define patient goals
   2. Identify what would get them closer to their goals
   3. Be a guide to whether the problem has improved
   4. Define what a patient can effectively accomplish
4. Implementation: Implementing nursing care according to the care plan, based on the patient’s health conditions and the nursing diagnosis. This is where you will document the care the nurse performs. A good implementation should:
   1. Define the nurse’s role
   2. Help you understand your role in their recovery
   3. Be different from the Provider’s role
5. Evaluation: Monitoring and documenting the patient’s status and progress towards meeting the planned goals. This allows you to modify the care plan as needed. A good evaluation should:
   1. Provide continuity of care
   2. Promote communication between nurses and shifts
   3. Move everyone towards the same goals