Components of a Nursing Care Plan

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11/12/2012
Components of a Nursing Care Plan

A nursing care plan is a set of guidelines that directs nursing activities for a patient. It details the entire steps needed from beginning to end of a patient’s care. The nursing care plan is also a framework that allows for evaluation of the effectiveness of the plan and it promotes continuity after the patient has left the healthcare facility. The four main components of a nursing care plan are: nursing diagnosis; expected outcomes; interventions; and evaluations. Documentation of the nursing care plan is important in order for the patient to receive proper care. All health team members can refer to the record to carry out the necessary steps within the plan (Module 6: Nursing Care Plan, 2012). A nursing care plan is defined by the nursing process. This process involves a scientific approach to problem-solving concerning patient care. The nursing process is individualized to each patient. The nursing process has five distinct steps. Those steps are: assessment; nursing diagnosis; planning; implementation; and evaluation. Following the nursing process is a method of organizing and prioritizing patient care. The process is an unbroken continuation of actions. Therefore, the five steps in the nursing process may be used repetitively for the duration of a patient’s care (Lippincott, Williams, & Wilkins, 2013). The design of an assessment is usually determined by the healthcare facility. This step in the nursing process requires that data be collected objectively and subjectively from the patient. Patients must be asked questions that allow them to provide as much information about their health related issue. A complete medical history along with the subjective and objective data assists the nurse in reaching a nursing diagnosis (Ackley & Ladwig, 2011). There are five labels associated with nursing

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