Nursing Care Plans

Client profile form and basic needs

essential client data not likely to change, profile and basic needs

What info is on a care plan (4)

1. basic needs and activities of daily living 2. medical and multidisciplinary treatment 3. nursing diagnoses and collaborative problems 4. special discharge needs or teaching needs

What documents are in a care plan (5 types)

1. client profile form and basic needs 2. preprinted, standardized plans 3. individualized nursing care plans 4. special discharge or teaching plans 5. computer plans of care

Why write a care plan (5 reasons)

1. to ensure healthcare is complete 2. to provide continuity of care 3. to promote deficient use of nursing efforts 4. to provide a guide for assessments and charting 5. to meet JC requirements

Difference between critical pathways and IPOCs (3)

Critical pathways: 1. organize care according to diagnosis 2. describe minimal standards of care 3. specify a timeline for interventions and outcomes IPOCs do not

Special discharge or teaching plans

address routine discharge planning and teaching needs

Standardized nursing care plans

detailed nursing care that is usually needed for a particular nursing diagnosis or for all nursing diagnoses commonly occurring with a medical condition

Student care plans

different from normal nursing plans because they are used for teaching, contain rationales to support decisions

Computer plans of care

electronic records of stored standardized care plans

Preprinted, standardized plans (6 parts)

include: 1. policies and procedures 2. protocols 3. unit standards of care 4. standardized nursing care plans 5. critical pathways 6. integrated plans of care

Critical pathways

outcomes-based, interdisciplinary plans that sequence patient care according to case type, emphasizing medical problems and interventions

Policies and procedures

rules and regulations to follow in order to handle a particular situation

Protocols

specific actions required for a clinical problem unique to a subgroup of patients containing both medical and nursing orders

Contrast between standard nursing care plans and unit standards of care (6)

standard nursing care plans: 1. provide more detailed interventions, adding to or deleting from unit standards 2. are organized by nursing diagnosis and include specific patient goals and nursing orders 3. are a part of the patient's comprehensive care plan and become part of the permanent record 4. describe ideal rather than minimum nursing care 5. allow you to incorporate addendum care plans 6. include checklists, blank lines, or empty spaces to individualize goals and interventions

Integrated plans of care (IPOC)

standardized plans that function as care plans as well as documentation forms with different forms or columns for each day

Unit standards of care

the care that nurses are expected to provide for all patients in defined situations, applying to every patient, not part of the care plan, describing the minimum level of care expected, resemble a list of things to do

Comprehensive nursing care plan

the central source of information needed to guide holistic, goal-directed care to address each patient's individual needs, made of several documents with dependent, independent, and interdependent nursing actions and combining standardized and individualized approaches to care

Individualized nursing care plans

used to address nursing diagnoses unique to a particular patient, reflecting the independent component of nursing practice because they can be entirely written by a nurse including diagnoses, goals, and nursing orders