Nursing Care Plans For Dummies will take the mystery out of care planning. Anyone in nursing school or anyone who has been in nursing school just wrinkled up their nose and cringed at the sight of those very words. Let’s face it, nursing care plans or any kind of care plans in healthcare are scary, tedious and require a lot of thought. The good news is nursing care plans for dummies can shed a little light on the mystery of care plans.
What Are Care Plans For Anyways
Nursing care plans are a plan of care for any patient that is undergoing treatment for a condition in the hospital, home health care or long-term care facility. They outline the following areas:
Nursing Diagnosis (Problem List) –
The nurse goes through and lists the top five needs of the patient in order of priority.
Goals For Patient –
This is what you are trying to achieve for the patient based on their needs. For example; a patient who has decreased mobility, the goal may be to ambulate 5 steps by a certain date.
Nursing Orders (Plan) –
These are the steps that need to be taken in order to attempt to achieve and meet goals. For example; nursing orders for aides to sit patient up on side of bed and the date, aides to have patient stand by date, and ambulate daily times how many days. This way, the plan of care can be communicated to the treatment team.
Evaluation and Outcome –
On the listed date, the nurse will evaluate the patient and list the outcome to see if they have met goals or need more time to meet the goals.
When a patient is admitted for treatment to any facility, the care plan is drawn up by the nurse and treatment team to make sure that all needs are met for the patient. They also help the discharge planner begin discharge planning and get reimbursement for medical expenses.
Nursing care plans are done in pencil due to the changing needs of the patient and goals that have been met can easily be erased or changed as the patient’s condition changes. After the care plans are drawn up, the treatment team (nurses, aides, therapists, dietary, etc.) will meet to discuss the needs of the patient according to the care plan.
Care Plans De-Mystified
The tricky part of care planning is not understanding what is okay to list as a “nursing order” that is within nursing scope of practice. This is what scares most nurses to want to turn and run as far as they can from them. Nursing care plans for dummies shows you the answer is easier than you think. Here goes:
A nursing order on a care plan is anything you can do for a patient without a doctor’s order. If a patient has a runny nose, you can hand them a tissue without a doctor’s order. If they are at risk for aspiration, you can elevate the head of the bed without calling the doctor. You can encourage fluid intake, unless they are on fluid restriction. You can encourage range of motion. So many things, but it is still hard to fathom. Just think of it as if you were taking care of a sick family member at home, what could you do for your loved one without calling the doctor if they sprained their ankle or had a cold? For the sprained ankle, you would encourage R.I.C.E. (Rest, Ice, Compression and Elevation). If someone has a cold at home, you might humidify the air, encourage rest and fluids and offer tissues. You might take their temperature Q 4 hours and offer Acetaminophen (making sure there are orders for Tylenol in the MD orders, of course).
It really is that easy. If you are unsure just run it by your nurse supervisor to see what is allowed on care plans without calling the doctor. I once got in big trouble for calling the doctor about orders for an enema. Turns out there were standing orders on enemas for all patients; therefore we could include it on our care plans. Always ask if you get stuck on one, but it is safe to put anything on one that you do not need a doctor’s order for.
Nursing Care Plans Just Got Less Scary
Nursing care plans for dummies shows you that it really is a piece of cake. As long as your nursing measure does not require a doctors order, go ahead and list it. Quality patient care depends largely on prioritizing patient needs and making patients comfortable. Understanding care plans has always been a rough thing for nurses, but if you use the format listed above the rest follow very easily. Nursing orders have always been hard to figure out since we need to remain “within our scope of practice.” Just think of a care plan as a plan you would do at home if a loved one is sick. It is everything you can do for a patient without having to call the doctor for orders. Happy Care Planning!