Sample nursing care plans, structured to meet the plan's clinical requirements with diagnostic indicators and desired, measurable outcomes, are available on the Internet from a number of sources. Sample plans range from activity intolerance to patterns of urinary elimination. Nursing care plan formats vary from facility to facility, so sample plans serve best as guides rather than an easily checked-off final plan.Continue Reading
The purpose of a nursing care plan is to ensure continuity of care by communicating a patient's needs and related instructions at shift changes or during nursing rounds. The care plan instructs the nurse taking over a patient's care what he should look for when he is with the patient, what needs to be done or tracked during the shift, such as blood draws or breathing treatments, and also any required communication with the family. Precise documentation is necessary on care plans because they are part of the medical record and impact not only patient care but also reimbursement of costs by insurance providers, Medicare and Medicaid.
Nursing care plans are generally organized in four sections: the nursing diagnoses or problem list, goals and outcome criteria, nursing orders and evaluation. Diagnoses recorded by a nurse are different than the medical diagnoses rendered by a physician. Nursing describes a patient's needs or symptoms from several perspectives, such as physical, sociocultural, psychological and spiritual. This is a key part of the plan since symptoms drive the plan of care. Goals and outcomes outline desired changes in the patient's condition in relation to the diagnoses. Nursing orders provide instructions as to actions necessary to reach the stated outcomes.Learn more about Social Services