Nursing Care Plan

Nursing Care Plan (NCP) is an essential part of nursing practice that provides a written means of planning patient care and discharge planning based upon nursing diagnosis using some guide to meet the patient's needs.

Care planning provides a "road map" of sorts, to guide all who are involved with a patient or resident's care. The care plan has long been associated with nursing, and many people believe (inaccurately, in my opinion) that is the sole domain of nurses.

Nursing Care Plan is a set of actions from the nurses, They will implement care plan to resolve nursing problems which happened to the patient during treatment. The Nurses identified all of patient's problem by accurate and comprehensive assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

To decided of Nursing Care Plan, For the first step the nurse collects subjective data and objective data, and then organizes the data into a systematic pattern as standard plans of care such as Marjory Gordon's functional health patterns. This step helps identify the areas in which the client needs nursing care.

Once the initial assessment is completed, a problem list should be generated. The nurse have to look at each problem and put the question "Can we make this problem better?" or "Can we keep this from getting any worse, or developing complications?".


After that, the nurse will put timing (review period) when the problem resolve or show signs of improvement. In the acute setting, the review period may be as short as next shift, next day or next week. In the long-term or home health setting, the review period will likely be longer.

When the problem is not getting better or not likely to improve, and deterioration is inevitable, then the nurse will decided last question "What can we do to provide optimal quality of life, comfort and dignity for this person?"

To make a better Nursing Care Plan, the Nurses must follow the steps of the nursing process bellow :

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)



2. Determination of the patient's problem(s)/Nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)



3. Planning (write measurable goals/outcomes and nursing interventions)



4. Implementation (initiate the care plan)



5. Evaluation (determine if goals/outcomes have been met)

Posted in: Nursing