Nursing care plan
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 diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.
Characteristics
- Its focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.
- It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.
- It focuses on client-specific nursing outcomes that are realistic for the care recipient
- It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.
- It is a product of a deliberate systematic process.
- It relates to the future
Elements
The nursing care plan consists of a nursing diagnosis with defining characteristics (subjective and objective data that support the diagnosis), related factors or risk factors, expected outcomes/goals, and nursing interventions.
See also