Nursing care plans allow healthcare providers to identify patient needs, recognize potential risks and communicate goals to achieve positive health outcomes. Care plans are one of the many tools used to create a continuity of care, or efficient sharing of information between providers to serve patient health needs.
For nursing students, care plans are also vital to improving critical thinking skills and applying the nursing process in daily practice. Writing nursing care plans and using nursing terminology as a student opens the doors to using evidence-based practices as a professional and supports harmonious work among healthcare teams.
The American Nurses Association (ANA) said nurses have long been the leaders in care coordination, including through plans of care.
“Registered nurses’ (RNs’) contributions to care coordination have long been a core professional standard and competency. It is what nurses do. It is what we have always done,” the ANA said. “Whether developing care plans guided by patients’ needs and preferences, educating patients and their families at discharge, doing their best to facilitate continuity of care for patients across settings and among providers, RNs make coordinated care possible.”
RNs seeking to advance their nursing careers, including through RN to BSN online programs, understand that care plans are foundational for nurse education. However, writing them can be challenging for nurses who may not understand their many vital components.
The Nursing Process and Care Plans
The original approach to care plans was developed by nursing theorist Ida Jean Orlando, who said nurses should interpret patient behaviors to determine needs and interventions.
Orlando’s Deliberative Nursing Process theory, published in 1961 in The Dynamic Nurse-Patient Relationship: Function, Process, and Principles, stated there was a five-step process for determining patient needs and achieving desired outcomes.
To ensure that everyone involved in the continuum of care follows a similar path, nurses write care plans that are typically formatted in five columns and include this information:
A nurse’s evaluation, or assessment, of a patient’s condition involves critical-thinking skills and information collection. The information is subjective, based on what the patient and caregivers may say, and objective, based on measurable data such as vital signs.
A nursing diagnosis is used to outline the plan of care. Derived through clinical judgment, it includes both problems the patient may face and possible interventions. Unlike a medical diagnosis conducted by a physician or family nurse practitioner (FNP), a nursing diagnosis focuses on the human response to medical conditions.
A nursing diagnosis is based on Abraham Maslow’s Hierarchy of Needs, a motivational theory that puts human needs in five categories: physiological (food, water, protection); safety (health, financial); belongingness (friendships); esteem (accomplishments); and self-actualization (full use of talents). Nurses document diagnoses based on information from NANDA International, which develops and refines nomenclature to reflect nursing clinical judgments.
In the planning stage, nurses formulate patient goals and outcomes based on evidence-based practices, which are foundational to preparing personalized nursing care plans. The planning goals should be specific, measurable, meaningful, action-oriented, attainable, results-oriented, realistic, time-oriented and timely.
For implementation, nurses put plans outlined in the care plan into action. Implementation can include direct or indirect care, standardized treatment protocols and evidence-based practices.
In evaluation, nurses review and reassess plans of care and update as needed. Reassessments can occur frequently depending on patient needs.
Nursing students who are writing care plans may also be expected to add a sixth column of information to explain their rationale behind the plans. Overall, writing nursing care plans allows nurses to prioritize patient healthcare needs and creates a continuum of care.
Successfully Writing A Nursing Care Plan
Because care plans serve as roadmaps for patient care, they must be written in a clear and concise manner. Nursing documentation is not only used in healthcare but also in billing and legal matters. New technology, including electronic health records (EHRs), have made it easier than ever to provide well-written and clear documentation that is easily shareable among healthcare teams.
In nursing school, students are expected to write care plans to learn the nursing process and develop critical thinking skills. As professionals, nurses build on the information learned through care planning to support positive patient outcomes.
Nursing students at Duquesne University’s RN-BSN online program learn about how care plans enhance professional work by using factual information to make clinical judgments.
About Duquesne University’s Online RN-BSN Program
Duquesne University’s 100 percent online RN-BSN courses are flexible so nurses can continue their education and manage personal and professional responsibilities simultaneously. The program provides a well-rounded education, focusing on advanced nursing competencies and culturally sound practices.
All of Duquesne University’s online RN-BSN students are paired with faculty mentors and provided with ample opportunities to collaborate with other BSN students from around the country. Duquesne University has been proudly educating nurses for more than 80 years as the founders of Pennsylvania’s first BSN program in 1937. Our faculty and staff experts work to help every student succeed. For more information, contact Duquesne University now.
Care Coordination and the Essential Role of Nurses: ANA
Nursing Process: NCBI
What is the difference between a medical diagnosis and a nursing diagnosis?: NANDA
The Five Levels of Maslow’s Hierarchy of Needs: Very Well Mind
Ida Jean Orlando – Nursing Theorist: Nursing Theory