In order to provide proper care for a patient, a nurse carries out an assessment and diagnosis procedure and then uses the information to develop an appropriate plan of care to meet the patient's health needs, according to NursingWorld. This care plan outlines nursing interventions and sets realistic and measurable short- and long-term goals for the patient.
The use of a well-written nursing care plan helps to ensure continuity of care between nursing staff and other professionals treating the patient, NursingWorld explains. The care plan also acts as a record of which treatments were effective and what goals were met, and this provides documentation of the effectiveness of the nursing care that a patient has received. As the patient responds to treatment or as his needs change, the nurse modifies the care plan to reflect these needs.
The nursing diagnosis that forms the basis for the care plan differs from the patient's medical diagnosis, explains RN Central. While the medical diagnosis refers to the disease process and outlines the treatment the doctor will provide, the nursing diagnosis refers to the patient's response to illness. This includes physical responses and socioeconomic or psychological factors affecting treatment, and it may even include consideration of the patient's spiritual beliefs.