Polski / pln
Český / czk
Slovenský / eur
How to write a nursing care plan in just a few steps
Nursing is undoubtedly a difficult and demanding profession. Nurses are dedicated to helping other people, whose life situation is often complicated in terms of health or social circumstances. Some aspects of this work are regulated by law, and they include the patient care process.
Since being a nurse is a socially responsible profession, nurses need to skilfully combine theory and practice – for instance, when creating a nursing care plan. What is it? How to write it? When is it required?
Contents:
What is an individual care plan?
How to write a correct nursing care plan?
Summary: how to make a care plan?
Key takeaways:
- Many aspects of nursing are regulated by law, and ensuring proper patient care is one of such aspects.
- Writing a nursing care plan is more than just a topic covered at university which may turn up in exams: it’s an actual and practical tool used by every nurse.
- To create a good care plan, you need to take several factors into consideration: from biological to social ones.
What is an individual care plan?
In Poland, the Act of 15 July 2011 on the professions of nurse and midwife, along with its amendments, regulates many aspects of nursing and specifies nurses’ responsibilities. In the second section of this act, particular nursing duties are enumerated, such as planning and providing patient care.
Future healthcare specialists learn about the nursing care process as part of the first year of their medical studies. This is no surprise: a nursing care plan is a crucial document that presents a personal approach to a patient and accounts for the patient’s individual needs and requirements. The main objective of putting a care plan in writing is to ensure complex and coordinated care that is focused on the patient. This is why such documents must follow certain guidelines.
What are they exactly?
How to write a correct nursing care plan?
Creating a personal care plan is a responsible task. To do it well, you need to take various factors into account:
- biological – diseases and coexisting conditions, treatment history, previous procedures, received medication, test results, general health, lifestyle;
- psychological – patient’s wellbeing, mental health, and behaviour, contact and cooperation with the patient, manner of expression, attitude towards others and self-attitude;
- social – marital status, current occupation, place of residence, education, support from other institutions;
- educational – patient’s awareness of the disease and their health situation as well as of the benefits and hazards of their current lifestyle.
If you take the above-mentioned factors into consideration, you will know how to write a comprehensive care plan and what to concentrate on. The factors are described in hierarchical order. However, as you can see, a thorough care plan covers numerous aspects, so it’s easy to get carried away and focus on the less crucial elements.
How to write a care plan to make sure it’s perfectly adjusted to the patient’s needs? Pay attention to the following:
- Avoid making medical diagnoses and listing symptoms or highlighting the patient’s social condition. The patient’s financial situation or the fact that they have cancer are not the problems that the care plan is meant to solve.
Remember about the hierarchy of care problems: start from the most important ones and end with the less significant issues. - Bear in mind that you might need to educate the patient: give them information about their condition alongside recommendations and precautions for daily care.
Create an action plan: identify the steps that must be taken to take proper care of the patient. - Provide some space for the presentation of how the action plan is implemented: specify the tests and other procedures performed as part of the treatment process.
Note: The action plan and its implementation may turn out to be two different things. The plan is theory: all the ideas and suggestions for actions that can be taken in a given case, regardless of the available funds, time and existing possibilities. The other part refers to the actions that have actually been taken: medical tests (along with their time and results) and procedures (performed by the nurse or by another person, e.g. a doctor).
Summary: how to make a care plan?
As writing nursing care plans is an important part of every nurse’s day-to-day work, university teachers often pay special attention to this task. That’s why care plans are common exam and thesis subjects.
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