Introduction

The nursing care plan is an agreement between the individual, or individual's responsible party, and the interdisciplinary team. When planning the individual's care, it is most effective to include everyone on the care team to ensure that the individual receives the most optimal level of services and care.

A Review of the Nursing Process

To effectively create a nursing care plan, one must understand the 5-step care-planning process: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).

Assessment

The RN uses a systematic way to collect and analyze data about an individual. This is the first step in the delivery of high-quality nursing care. Included in the assessment is the physiological information, the psychological, sociocultural, spiritual, economic, and lifestyle factors of the individual. The assessment can be completed using Subjective and Objective Data.

Subjective data is information that the individual tells you. You cannot see or measure the information. (For example, pain, nausea, vertigo or anxiety.) Subjective data can be mental, such as confusion or an inability to concentrate, or physical, such as reported feelings of heaviness or tiredness.

Objective data can be observed, measured, and verified by you. Examples include vital signs, lab results, care-recipient's weight, difficulty with breathing edema, and actions.

Diagnosis

The nursing diagnosis is the nurse's clinical judgment about the individual’s response to actual or potential health conditions or needs. The nursing diagnosis reflects the individual’s problems are from the nursing perspective. It also describes the individual’s response to the condition rather than identifying the condition. The nursing diagnosis is the basis for the plan. The plan can relate to problems faced due to the medical diagnosis. The medical diagnosis itself should not appear in the plan.

Planning

In the planning step, the nurse, along with the individual, sets measurable and achievable short- and long-range goals for the individual. The plan or outcomes are based on the individual’s assessment, nursing diagnosis and the individual's input of his or her needs and desires. The nurse must use decision-making and problem-solving skills to determine appropriate outcomes for the individual. There are 3 stages in the planning process.

• Initial planning is based on the admission assessment.
• Ongoing planning is done by all nurses who provide care for the individual at the beginning of each shift. The nurses continually assess any changes in the individual’s condition on a daily basis.
• Discharge planning begins at admission and plans for the needs of the individual after discharge (used mainly for individuals who are receiving skilled care).

Implementation

The planned nursing care for the individual is implemented so that the continuity of care for the individual is provided and continued, regardless of the care setting. In the implementation stage, the questions that need to be answered are, “What care has been provided to the individual?", What were the actions taken?”, and “How often were those actions completed?”.

Evaluation

Once all the nursing action has taken place, the nurse completes an evaluation to determine if the goals of the individual have been met. The individual’s response and the effectiveness of the care provided must be continuously evaluated and the nursing care plan is modified as needed. The nurse annotates and documents the response to the interventions and whether the response to the care was the expected outcome. The possible individual outcomes are described under the following terms:

• The individual’s condition has improved.
• The individual’s condition has stabilized.
• The individual’s condition has deteriorated.

If the individual's condition has shown no improvement, the nursing process begins again from the first step.

Evidence-Based Nursing Care Plans

Care must be provided in a way that prevents any decline in an individual's abilities or condition unless the decline cannot be prevented due to illness. Person-centered care plans are based on the current functionality and should be implemented to ensure that there are no declines.

If a decline is noted, that's considered a change in condition or status, and another assessment needs to be done to determine what care can be planned to increase the individual’s functionality back to previous levels.

An Evidence-Based Nursing Care plan takes into consideration the following items:

• It prioritizes key nursing diagnoses, outcomes, and interventions for each individual's plan of care.
• It enables care providers to identify both recipients’ needs and providers’ requirements for safe care.
• It monitors the individual’s progress throughout an episode of care and across the continuum of care.
• It includes NANDA International (NANDA-I), Nursing Interventions Classification (NIC), & Nursing Outcomes Classification (NOC) (NNN) into evidence-based practice outlines.

NANDA-I, NIC, and the NOC are comprehensive, research-based, standardized classifications of nursing diagnoses, nursing interventions, and nursing-sensitive individual outcomes. They allow for the following:

• They standardize clinical reasoning terms (diagnoses, interventions, and outcomes) in your organization as a basis for determining effective care.
• They use clinical judgment through the use of standardized definitions for all terms, evidence-based assessment criteria for selecting appropriate diagnoses, along with activities for interventions and indicators for all outcomes.
• They populate electronic health record assessments with evidence-based criteria that support effective clinical decision-making, outcome measurement and individualized intervention.

Developing Nursing Care Plans

The team caring for the individual must work collaboratively to synthesize the information and reach consensus around treatment and goals for care. An interdisciplinary team includes the individual and/or his or her family members, the physician, physical therapist, occupational therapist, dentist, dietician, social worker, and nurses which include the CNA.

The nursing care plan details how the day-to-day health of the individual will be managed. It is developed using the comprehensive assessment that’s completed on the individual. The plan includes the individual’s needs and how those needs will be provided. It should be person-directed, created with the individual and/or his family member or legal representative and tailored to the individual.

When the care plan is developed based on the individual’s needs, the likelihood of the person following the care plan increases greatly.