Student nurses spend their entire course curriculum learning how to prepare elaborate care plans for their patients. Then they get to their first job all prepared to present their very best care plans and soon figure out they don’t do care plans in the real world of nursing…or do they?
The whole purpose of devising and writing those time-consuming documents was to teach student nurses how to follow the Nursing Process and develop a plan for providing each and every patient they encounter throughout their nursing career with the best possible care. The care has to be unique and patient centered. It must be built on evidence-based care and it must be the best possible quality care that the nurse can provide. The care must result in improved outcomes for the patient and be the best possible.
Prioritizing Patient Care
Care plans help the nurse prioritize the care based on patient needs such as those outlined in Maslow’s Hierarchy. In addition, nurses need to base their care on needs identified through patient assessment which include immediate needs that fit into the ABCs such as Airway, Breathing and Circulation/Cardiac problems. Other concerns to prioritize include abnormal vital signs, or laboratory or other diagnostic tests with abnormal or critical variations. Issues such as a change in mental status, pain, untreated medical problems that need treatment or medications, elimination issues, lack of knowledge, family coping issues, activity or rest also contribute to the prioritizing of patient care.
The art and science of nursing care revolves around care planning. Whether it gets written up in an elaborate paper or used mentally to plan the nurse’s day and prioritize patients and care, nursing care plans are an essential part of daily nursing care. The purpose of writing all of those care plans is for the student nurse to have a full understanding of the process of nursing assessment and care. By graduation, the student should be well-prepared to provide quality nursing care.
Outcomes Measure the Quality of Care
Patient outcomes depend on the care they receive. This includes education provided to patients and their caregivers or family members and covers long term care issues and what/when to report to their healthcare provider. Successful or improved outcomes are vital to reimbursement and ratings of the facility. Carrying out a plan of care efficiently and effectively seriously impacts the outcomes.
Discharge planning begins at admission and needs to be an important factor in the overall care plan for the patient. Understanding the needs for a continuum of care or handing off total responsibility to the patients and/or caregivers is an important factor in deciding goals and discharge plans.
Communication and Documentation are Essential
Utilizing the time spent with patients effectively also depends on careful care planning and communication. Documentation as well as the handoff communication from one shift to another needs to include an update on the patient’s status and progress towards the goals and any changes made to the plan so that time is not wasted re-inventing the wheel each shift. Nursing continuing education is often focused on improving documentation and communication because of the importance.
During assessment rounds each shift nurses should evaluate the patient’s knowledge base and abilities in regard to his care and the progress towards goals. What does he know about his condition, his plan of care and goals? Does he see progress? If caregivers are present, where are they in this process? Verify and validate the handoff report received and proceed accordingly. Review if needed to reinforce the previous teaching. Any adjustments made need to be documented and communicated with all involved to stay on the course towards meeting the goals set or altered.
Are care plans really necessary? Yes, they are at the very basis of nursing care. Are they formal and written? Probably not. But the process is standard and follows the Nursing Process to assess, plan, implement, and evaluate based on the data derived. Communication and accurate nursing documentation are essential to the success and improved outcomes for the patient.