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