Nursing care plan

A nursing care plan provides direction on the type of nursing care the individual/family/community may need . The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the veterinary profession. The Care Plan includes the following components; assessment, diagnosis, expected outcomes, interventions, rationale and evaluation. According to Ballantyne care plans are a critical aspect of nursing and they are meant to allow standardised, evidence-based holistic care. It is important to draw attention to the difference between 'care plan' and 'care planning'. Care planning is related to identifying problems and coming up with solutions to reduce or remove the problems. The care plan is essentially the documentation of this process. It includes within it a set of actions the nurse will apply to resolve/support nursing diagnoses identified by nursing assessment. Care plans make it possible for interventions to be recorded and their effectiveness assessed. Nursing care plans provide continuity of care, safety, quality care and compliance. Nursing care plans promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid.

A care plan includes the following components;

A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. Using electronic devices when creating nursing care plans are a more accurate, accessible, easier completed and easier edited, in comparison with handwritten and preprinted care plans.

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