A nursing care plan (NCP) outlines the goals, interventions, and actions a nurse will use to evaluate a patient's healthcare needs and provide care. Essentially, a nursing care plan is like a guidebook for individualized nursing care that provides comprehensive and continuing treatment for a patient. For a nursing care plan to be effective, it should consider a patient’s current condition and medical history as well as offer realistic and measurable goals and interventions that pave the way for the most favorable patient outcomes.
Accordingly, healthcare facilities provide treatment dictated by nursing care plans—developed through a collaborative process among nurses, patients, and other healthcare team members—as part of their strategy for integral and patient-centered care.
What Does NCP Mean in Medical Terms?
In medical terms, NCP stands for “nursing care plan.” It is a methodical and often visual approach used by nurses in medical settings to outline diagnoses, interventions, and strategies to address a patient’s healthcare needs. Consequently, an NCP is an essential tool that provides focused, high-quality, and individualized care to patients.
What Is a Nursing Care Plan (NCP) in Practical Terms?
An NCP serves as a guide to help a healthcare team identify and treat a patient’s condition. In addition, a thorough NCP can be divided into steps and offers a systematic approach to achieving good patient health outcomes. A nurse can think of a nursing care plan as a blueprint for helping a patient in need. In other words, NCPs can help a healthcare professional to figure out how to form a nursing diagnosis for a patient. Furthermore, a nursing care plan defines what actions a nurse will need to take in order to provide appropriate interventions.
In order to fill out an NCP, a nurse should be familiar with each component that makes up a comprehensive nursing care plan. The key components that make up a nursing care plan are as follows:
1. Patient Assessment
A patient assessment can help a nurse develop a comprehensive picture of the patient's health status. Writing a patient assessment involves gathering relevant information about the patient's medical history, current symptoms, and any other important details. Additionally, a patient assessment can include objective observations, such as vital signs or physical examination findings. A patient assessment can also include subjective assessments, such as a patient’s psychosocial, emotional, economic, and current cognitive status. Finally, a patient assessment can include statements that come directly from the patient or the patient’s family about a patient’s condition.
Learn More: Objective Vs Subjective Data in Nursing
2. Nursing Diagnosis
What is a nursing diagnosis? The North American Nursing Diagnosis Association (NANDA) defines a nursing diagnosis as a clinical judgment concerning a patient’s response to certain health conditions or life processes. This diagnosis is based on findings from the patient assessment and can help determine necessary interventions and treatments. It also provides a certain amount of accountability for a nurse to follow through on treating a patient once a diagnosis has been made.
A nursing diagnosis is an essential component of a nursing plan because it involves a nurse making a discernible and educated judgment about a patient's condition and then following up with appropriate nursing interventions.
3. Projected Outcomes
After providing a proper patient assessment and nursing diagnosis, nurses project healthcare outcomes. In nursing, SMART stands for Specific, Measurable, Achievable, Relevant, and Time-bound. These elements make up the criteria for establishing “smart goals” in nursing that are clear, quantifiable, attainable, and relevant to patient care.
A smart-goals framework also has a defined completion timeline. Therefore, possible outcomes can be outlined in a nursing care plan as both short-term and long-term goals. For example, a short-term goal may be a shift in behavior and an improvement in symptoms that a patient may achieve in a few hours after treatment. Whereas a long-term goal may be a more permanent shift in behavior and improvement in symptoms that a patient experiences months or years after receiving treatment.
4. Nursing Interventions
After a nursing diagnosis has been made and short-term and long-term goals have been set, a nursing intervention should be implemented. Nursing interventions in healthcare refer to the actions and strategies implemented by nurses to treat and maintain the health of patients. Nursing interventions should offer both immediate and long-term results. For example, an immediate nursing intervention could be the administration of intravenous (IV) fluids to a patient who is too sick to swallow fluids or eat solids. A more long-term nursing intervention could be treating a patient until they are able to eat solid foods.
Additionally, nursing interventions may also involve advocating for patients' rights, promoting preventive measures, and ensuring a safe and comfortable environment for optimal patient outcomes. These measures can include changing the position of the patient frequently, speaking with their family, and closely monitoring a patient’s recovery process.
5. Observations and Evaluations
An evaluation is the final component of a nursing care plan; it analyzes whether the goals set in a nursing plan have been achieved. It also includes identifying any areas that need improvement and making necessary adjustments to optimize a patient’s care and treatment.
Short-term goals should be met for a nursing plan to be considered effective. Subsequently, once a patient has been discharged, a clear and detailed discharge plan should outline nursing interventions that will help a patient meet long-term treatment goals.
What Are Some Nursing Care Plan Examples?
Nursing care plans can be broken down into four classification types: informal, formal, standardized, and individualized.
- Informal nursing care plan: A plan of care for a patient and a strategy for action that exists only in the mind of the nurse
- Formal nursing care plan: A written or computerized plan that organizes and coordinates information about a client’s care. Formal NCPs should be regularly updated based on the patient's progress and changes in their condition to ensure optimal outcomes.
- Standardized nursing care plan: A formal plan that specifies care needed for a group of patients with similar conditions
- Individualized nursing care plan: A personalized care plan that is specific to a patient’s condition and needs
Nursing care plans are documents that contain crucial healthcare protocols. Some nursing care plans utilize a four-column nursing plan, while others may be more detailed and offer a five- or even six-column format.
The following is an example of a nursing care plan in a five-column format that depicts a hypothetical patient care strategy for a dehydration case:
When shift changes occur, NCPs ensure that nurses are on the same page by providing tools to easily track and communicate patients’ care plans to other members of the healthcare team. This can help healthcare professionals provide consistent and effective care while ensuring the best possible outcomes for patients.
What Are Standardized Care Plans?
In nursing, standardized care plans are broad, pre-determined plans of care that healthcare providers use as guides to provide consistent and evidence-based care to patients with similar health conditions. These care plans are structured plans of action and have been developed based on nursing diagnoses, patient’s medical histories, and physical examinations.
Similar to other nursing care plans, standardized nursing plans will always include nursing diagnoses, nursing interventions, outcomes, goals, and evaluations. Ultimately, standardized care plans can help reduce variation in care and improve communication among members of the healthcare team. Standardized NCPs can also assist nurses in providing high-quality care and promoting patient safety.
What Are Personalized Care Plans?
A personalized care plan, also referred to as an individualized care plan, is a nursing plan that is tailored to meet the specific needs of a patient. Typically, a personalized care plan takes into consideration a patient’s physical, emotional, and social needs. This has also been described as a “whole-person approach” to treatment planning.
As such, a personalized care plan is ideally created to be patient-centered and can improve the quality of care for patients who suffer from chronic conditions. That’s because an individualized care plan takes input from the patient into account. This collaboration can mean discussing a treatment plan in depth with a patient and asking them to create goals that align with their lifestyle, preferences, and core values. As a result, individualized patient care plans are crucial for improving patient care because they address each patient's unique needs and encourage tailored nurse interventions to help a patient fully recuperate.
Why Are Nursing Care Plans Important?
Developing a clear and comprehensive nursing plan can create better patient outcomes, lead to higher patient satisfaction, and dramatically improve the quality of care within a healthcare setting. Furthermore, nursing care plans help healthcare providers deliver seamless care by creating a systematic approach that defines a patient's requirements, goals, and treatments.
Similarly, having a centralized document that all healthcare team individuals can refer to helps ensure the delivery of appropriate and effective care at all times. As technology advances, nursing care plans have the potential to revolutionize patient care by offering organized, safe, and compassionate care to patients across the country.
See Also: 10 Ways Nurses Can Optimize Their Day
