Care planning is an essential part of healthcare but is often misunderstood or regarded as a waste of time. Without a specific document delineating the plan of care, important issues are likely to be neglected. Care planning provides a “road map” of sorts, to guide all who are involved with a patient/resident’s care.
The care plan has long been associated with nursing, and many people believe that it is the sole domain of nurses. To be effective and comprehensive, the care planning process must involve all disciplines that are involved in the care of the patient/resident.
Nursing care plans are an essential part of nursing practice that provide a written means of planning patient care and discharging plan based upon nursing diagnosis. Nursing care plans function as a means of communicating patient care needs between members of the nursing team to ensure those needs are met. Written nursing care plans also serve as a means to document changes in a patient’s condition, adjustments, or additions to nursing diagnosis, as well as patient responses to nursing or medical treatment. Nursing care plans enable nurses to provide a holistic approach to patient needs both while hospitalized and after discharge.
Nursing care plans must always be individualized for each patient’s needs. It would be better if nurse staffing ratios would allow nurses adequate time to sit at a desk and utilize their expertise to create a complete admission to discharge and home care plan after careful review of patient history, medical records, physical assessment, and applicable nursing diagnosis. We live in an imperfect world however and nurses do not have adequate time to research each patient’s history and needs and write a comprehensive plan of care from scratch for each patient during their hectic shift. Understaffed nurses try to keep up, but when time is short mistakes happen more easily and some aspects of the nursing care plan may be omitted. Stock care plans, care plan software, and nursing care plan books are useful as reference tools to help ensure potential problems associated with their particular patient are not overlooked during the nursing care planning process.
The ultimate purpose of nursing care plans is to guide all who are involved in the care of this person to provide the appropriate treatment in order to ensure the optimal outcome during his/ her stay in our healthcare setting. A caregiver unfamiliar with the patient/resident should be able to find all the information needed to care for this person in the care plan.
It is important to design nursing care plans that provide adequate safety to the patient, make things less distressing to the family, and utilizes resources appropriately.
