As a nurse ensuring your patient’s health and recovery is your main duty. And sometimes you might find yourself in a position providing an adequate nursing care plan for your patients. How can I prepare a nursing plan that includes every aspect of the nursing process and patient care? Nursing care plans are vital for providing care to patients based on the patient’s health condition, prognosis, and diagnosis.
Quality care plans help physicians and nurses to focus on patient’s recovery in a way so that they can provide evidence-based care. It also ensures continuity of care across various nursing shifts and promotes interprofessional collaboration. While it’s not possible to create unique health care plans for each patient, it is important to formulate an effective common nursing plan. Here are some tips on how to prepare a perfect nursing care plan:
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Why is a nursing care plan important?
The nursing care plan is the core part of patient care as it will take a detailed history of patient healthcare data to provide the utmost patient care plan for treatment and fast recovery. It provides a focus on individualized healthcare plans. So, the physicians and other duty nurses can have a proper understanding of the whole treatment and healthcare options. And it also helps you understand the prioritization of treatment plans – just like a step by step process, all the prioritized tasks will be carried out earlier. A good nursing care plan will act as a communication tool between other faculties.
Consult Your Patient
Access your patient to know what they are suffering from. This is the basic step of any health care plan. First, you need to know “what” to determine “why” it is happening and “how” you can make their situation better. Get all the health information related to your patient to curate a plan. Collect all the minor and major details about their healthcare history, family history, allergies, when they developed the disease, what are the related symptoms, whether they are undergoing any specific medications or not, and so on. All these data will be needed at certain times of their healthcare plans.
In certain situations, nurses should find out their family healthcare history to find out whether this disease runs in the family. It is important to take note of their living situation, their dietary plans, and the more information about the people they are living with when they first contact the disease. A basic physical examination should be performed to take note of his vital organ functionalities. Each of these data will help you to determine an improvised healthcare plan.
Analyze the Information
Now you have collected all the basic and primary information about your patient, it’s time to identify what their symptoms and health problems are. Information gathered about them should be studied properly to come up with a detailed patient care plan. Conduct physical assessments to make sure they are all in a good condition. And sometimes you might have to find out their mental wellness to prescribe further treatments. In some cases, you might have to mentally prepare the patient before critical operations. Making them aware of the medical procedures and what to expect is part of the plan.
After analyzing the results you have to write down a treatment plan that incorporates patient health history, recovery plans, and further treatment methods. You might have to write down the phases they are going through and what could worsen or improve their condition. Create plans in a way that you could see the improvements of the patient and how you would know they were improving.
Set Goals
Write down your notes – put the pieces together. Based on the diagnostic you have to set goals. Your goals should be realistic to implement and should bring actual results in a short span of time. And they should be measurable to see if you’ve reached your goals or not. Create plans in a step by step process, so it will be easier to catch up with results. Based on the situation, you might have to create short term or long term plans and some might be executed urgently.
Every patient case might not be the same – as per the situation you might have to incorporate interprofessional involvement in each step of the plan. Based on the primary procedures you might have to include various pain relief therapies, mental support programs, and other professionals from the industry.
Evaluate the Patient Regularly
Curating a detailed plan and sticking with them until you see results might seem a good plan. But sometimes, you might have to change your care plan. For example, after a major operation, some patients may need longer recovery time than expected or some may get infected. These times, your top priority will be to reduce post-surgery complications as it may put their lives in danger. This means you might have to prepare to change your plans as per the patient’s condition.
Regularly evaluate the health condition of your patient. This will help you better understand how your plan is executing, whether you have to update the plan or not. And you have to educate the patient and their family members during each treatment procedure – including why it is needed, what to expect during and after the treatment plan, and the pre and post preparations.
Complete Patient Care Plan
Complete your patient care plan and improvise the plan if it needs any modifications. A nursing care plan is different from a medical diagnosis. Sometimes it might seem very confusing to curate a plan because you will have plenty of common symptoms to specifically diagnose what the actual problem is. It is easier to get confused especially if you are a student. But with practice, this will be easier for you. If you are new to curating a detailed nursing care plan you can seek help from your colleagues. Examining a nursing care plan is beneficial for students and an advanced nursing program will help you to better understand the care plan. This might seem like an unwanted task during your heavy class times but you will realize it does matter.