FORMULATION
OF CARE PLAN
BY:- Firoz Qureshi
Dept. Psychiatric Nursing
INTRODUCTION
The nursing care plan is written
guide that organizes information
about a client’s care into a
meaningful whole .
It includes the actions nurses must
take to address the clients nursing
diagnosis and meet the stated goals
.
DEFINITION
A plan ,based on nursing and
assessment and a nursing diagnosis
,carried out by a nurse .
PURPOSES
To provide direction for individualized
care of the client .
To provide for continuity of care
To provide direction about what needs to
be documented on the client ‘s progress
notes
To serve as a guide for assigning staff to
care for the client .
WRITING A NURSING PLAN OF CARE
A nursing plan of care documents the
problem solving process.
A nursing care plan outlines the nursing
care to be provided to an individual
/family /community it is a set of actions
the nurse will implement to resolve
/support nursing diagnosis identified by
nursing assessment .
CONT…...
The plan is a critical element in focusing
nursing activity .
To serve as evaluation criteria and meet
the standards of the joint commission
for accreditation of health care
organizations (1996).
T WO IMPORTANT CONCEPTS GUIDE A
NURSING PLAN OF CARE
The plan of care is nursing centered
The plan of care is a step by step
process .
NURSE WORK
What is a care plan.
Why do nurse write care plans
What are the different parts of a care
plan
What other paper work will I need to
know
How am I evaluated
NURSING CARE PLAN
Provide a direction for individualized
patient care.
Provide continuity of care for the patient
with all hospital departments.
Provide documentation on patient and
family needs.
A STEP-BY STEP PROCESS IS EVIDENCED BY
THE FOLLOWING
Sufficient data are collected to
substantiate nursing diagnosis .
At least one goal must be stated for each
nursing diagnosis .
Outcome criteria must be specifically
designed to meet the identified goal .
Each intervention should be supported by
a scientific rationale .
CONT….
Evaluation must address whether each
goal was completely met or ,partially
met .
GUIDELINESS FOR WRITING NURSING CARE
PLAN
1.Date and sign the plan .
2.use the category headings
3.Nursing Diagnosis
4. Goals /Outcome Criteria
5.Nursing Orders Criteria
6.Evalution and include a date for the
evaluation of each goal .
7.Use standardized medical or medical
symbols and key words rather than complete
sentences to communicate your ideas.
CONT….
Refer to procedure books or other sources
of information rather than including all the
steps on a written plan .
Tailor the plan to the unique characteristic
of the client by ensuring that the client
choices ,such as preferences about the
time of care and the methods used are
included .the reinforces the clients
individually and sense of control .
CONT…..
Ensure that the nursing plan incorporate the
preventive and health maintenance aspects as
well as restorative .
Ensure that the plan contains orders for
ongoing assessment of client .
Include collaborative and coordination
activities in the plan.
Include plans for the client discharge and
home care needs .
T YPES OF NURSING CARE PLANS
As you care for people in various health
care facilities ,you will discover a variety
of nursing care plan formats .
1 . STUDENT NURSING CARE PLANS
2.TEACHING PLANS
3.CASE MANAGEMENT CARE PLANS
4.COMPUTERIZED NURSING CARE
PLANS
CARE PLAN
Provides acuity for staffing needs.
Provides reimbursement for insurance
which was started by Medicare and
Medicaid and now used by all insurance
companies. This is how hospitals and
patients receive payment.
NURSING DIGNOSIS
Related NANDA Nursing Diagnoses
• Ineffective Role Performance
• Body Image Disturbance
• Chronic low self‐esteem
• Self‐esteem disturbance
• Situational low self‐esteem
• Personal Identity disturbance
HOW TO WRITE NURSING CARE PLAN
Begin with a complete assessment of
your patient. Get as much information
as possible from the chart, such as lab
data, x-ray reports,
physician history and physical exam
DATA COLLECTION
Subjective-This is what your patient tells
you.
“ My head hurts” States on scale of 1-10
My head hurts at 8.
Objective- This is what you see.
Patient rubbing head.
TALK TO YOUR PATIENT
This helps you decide what is really
wrong with your patient. You must listen
to know what they are not telling you.
NURSING DIAGNOSIS
It is not a medical diagnosis
A nursing diagnosis is the plan of care
for your patient which all member of the
staff will follow as they care for the
patient.
INTERVENTION
What are you going to do to help your
patient reach their goal. This is what you
do daily for your patient. If you give your
paper to a peer would they be able to
follow your intervention or plan of care.
NURSING RATIONALE
This is the scientific reason you
did this for your patient. You
must tell us (cite) where you got
your information. This could be
your from your books or a reliable
internet source.
EVALUTION
Did your patient reach their goal in the
time frame that you allowed for them
Did your patient not reach their goal and
do you need to extend the timeframe or
is this an unreachable goal and you need
to start over?
PAPER WORK IN CARE PLAN
We have covered every aspect of this
paper
This is the form you will turn in daily and
it will help you write your care plan
This form will be given to you on Friday
after clinical. If your instructor is very
busy, you will receive it on Monday.
EXAMPLE OF NURSING CARE PLAN
