What Is A Nursing Diagnosis and Care Plan?
The Purpose of the Written Care Plan
• Care plans provide direction for individualized care of the client. A care plan flows from each patient’s unique list of diagnoses and should be organized by the individual’s specific needs.
• Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds.
• Care plans help teach documentation. The care plan should specifically outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require.
• They serve as a guide for assigning staff to care for the client. There may be aspects of the patient’s care that need to be assigned to team members with specific skills.
• Care plans serve as a guide for reimbursement. Medicare and Medicaid originally set the plan in action, and other third-party insurers followed suit. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client. If nursing care is not documented precisely in the care plan, there is no proof the care was provided. Insurers will not pay for what is not documented.
The goal as established in a nursing care plan — in terms of observable client responses — is what the nurse hopes to achieve by implementing nursing orders. It is a desired outcome or change in the client’s condition. The terms goal and outcome are often used interchangeably, but in some nursing literature, a goal is thought of as a more general statement while the outcome is more specific. For example, a goal might be that a patient’s nutritional status will improve overall, while the outcome would be that the patient will gain five pounds by a certain date.
Nursing orders are instructions for the specific activities that will perform to help the patient achieve the health care goal. How detailed the order is depends on the health personnel who will carry out the order. Nursing orders will all contain:
• The date
• An action verb like “monitor,” “instruct,” “palpate,” or something equally descriptive
• A content area that is the where and the what of the order, for example, placing a “spiral bandage on the left leg from ankle to just below the knee”
• A time element will define how long or how often the nursing action will occur
• The signature of the prescribing nurse, since orders are legal documents.
Finally, in the evaluation, the client’s health care professionals will determine the progress towards the goal achievement and the effectiveness of the nursing care plan. The evaluation is extremely important because it determines if the nursing interventions should be terminated, continued or changed.