What is a Nursing Care Plan?
The end product of the nursing process’ planning phase is a plan of care or also known as a nursing care plan (or simply a care plan). We have collated and created a wide selection of nursing care plans for our nurses and student nurses to use. Feel free to use these nursing care plans (NCPs) to your assignments and requirements.
Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the planning process, quality and consistency in patient care would be lost.
Care plans can be informal or formal:
- Informal nursing care plan is a strategy of action that exists in the nurse’s mind.
- Formal nursing care plan is a written or computerized guide that organizes information about the client’s care.
Formal care plans are further subdivided into standardized care plan and individualized care plan:
- Standardized care plans specify the nursing care for groups of clients with common needs.
- Individualized care plans are tailored to meet the unique needs of a specific client or needs that are not addressed by the standardized care plan.
What is a Nursing Diagnosis?
A nursing diagnosis may be part of the nursing process and is a clinical judgement about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment.
Here are the four categories/structures of nursing diagnosis provided by NANDA-I system:
- An actual diagnosis is a client problem that is present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms.
- Examples: Ineffective Breathing Pattern and Anxiety, Acute Pain, and Impaired Skin Integrity.
Risk Nursing Diagnosis
- A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
- For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status.
- Wellness Diagnoses describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement. Examples of wellness diagnosis would be Readiness for Enhanced spiritual Well Being or Readiness for Enhanced Family Coping.
- It is a diagnosis that is associated with a cluster of other diagnoses. Example is Rape Trauma Syndrome.
Here is a list of nursing care plans that can be found in Nurseslabs: