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Questions and Answers
What is the primary purpose of a formal nursing care plan?
What is the primary purpose of a formal nursing care plan?
Which of the following best describes an individualized care plan?
Which of the following best describes an individualized care plan?
When does discharge planning typically begin?
When does discharge planning typically begin?
What is included in a complete plan of care?
What is included in a complete plan of care?
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What role do nursing protocols play in patient care?
What role do nursing protocols play in patient care?
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What is ongoing planning primarily concerned with during a nursing shift?
What is ongoing planning primarily concerned with during a nursing shift?
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Which type of nursing care plan is usually an informal mental strategy used by nurses?
Which type of nursing care plan is usually an informal mental strategy used by nurses?
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Why is it important for nurses to develop a problem list?
Why is it important for nurses to develop a problem list?
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What is a necessary component when documenting a nursing care plan?
What is a necessary component when documenting a nursing care plan?
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When setting priorities in nursing care, which type of need is considered a high priority?
When setting priorities in nursing care, which type of need is considered a high priority?
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Which of the following should NOT be included in a nursing care plan?
Which of the following should NOT be included in a nursing care plan?
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What approach should nurses take when tailoring care plans to a client?
What approach should nurses take when tailoring care plans to a client?
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What factor is essential to consider when establishing priorities in nursing care?
What factor is essential to consider when establishing priorities in nursing care?
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Which of the following best describes the role of multidisciplinary collaboration in nursing care planning?
Which of the following best describes the role of multidisciplinary collaboration in nursing care planning?
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What is a key benefit of utilizing standardized symbols and keywords in nursing care plans?
What is a key benefit of utilizing standardized symbols and keywords in nursing care plans?
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How often should ongoing assessments be included in a nursing care plan?
How often should ongoing assessments be included in a nursing care plan?
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What do policies and procedures primarily govern in a healthcare setting?
What do policies and procedures primarily govern in a healthcare setting?
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Which format for nursing care plans typically includes four columns?
Which format for nursing care plans typically includes four columns?
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What is a key characteristic of nursing protocols?
What is a key characteristic of nursing protocols?
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What distinguishes individual care plans from standardized care plans?
What distinguishes individual care plans from standardized care plans?
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Which of the following is an example of a standing order?
Which of the following is an example of a standing order?
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In what way do multidisciplinary (collaborative) care plans function?
In what way do multidisciplinary (collaborative) care plans function?
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What is typically true of student care plans compared to professional care plans?
What is typically true of student care plans compared to professional care plans?
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Which of the following correctly defines a standardized approach to care?
Which of the following correctly defines a standardized approach to care?
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Study Notes
Standardized Approaches to Care Planning
- Standards of care outline nursing actions for clients with similar medical conditions and are achievable rather than ideal. They usually rely on agency records for reference in client care plans and do not include medical interventions.
- Protocols indicate common actions required for particular client groups and may include primary care provider orders and nursing interventions. Examples include protocols for admitting clients to the ICU or administering magnesium sulfate to clients with preeclampsia.
- Policies and procedures govern the handling of frequently occurring situations, such as visitor restrictions in a hospital.
- Standing orders are written documents regarding client care policies, rules, regulations, or orders. They empower nurses to take specific actions under certain circumstances, often when a physician is unavailable.
- Formats for Nursing Care Plans vary across health agencies. Some are organized in columns for diagnosis, goals/desired outcomes, nursing interventions, and evaluation, while others use different combinations of these elements.
- Student care plans are detailed, handwritten, and include a rationale for interventions with citations for literature used.
- Concept maps, also known as mind maps, are visual tools used in student learning. They consist of boxes or circles connected by arrows or lines, facilitating an understanding of a specific disease.
- Computerized care plans allow for standardized and individualized NCP creation and storage.
- Multidisciplinary or collaborative care plans, also called critical pathways, are standardized plans that specify a sequence of care on a daily basis.
Types of Planning
- Initial planning is initiated upon admission after the initial assessment, where nurses conduct the admission assessment and develop a comprehensive plan of care.
- Ongoing planning is conducted by all nurses working with the client to individualize the initial plan. It occurs at the beginning of each shift to plan care for the day.
- Discharge planning anticipates and plans for needs after discharge, recognizing that clients often require continued care. This process begins at the first client contact and involves ongoing comprehensive assessment to gather information about the client's ongoing needs.
Developing Nursing Care Plans
- Informal nursing care plans are strategies for action that exist in the nurse's mind, such as planning to reinforce education for a tired client when they have rested.
- Formal nursing care plans are written or computerized guides that provide organized information about client care, promoting continuity of care.
- Standardized care plans are formal plans that specify nursing care for groups of clients with similar needs, such as all clients with a myocardial infarction.
- Individualized care plans are tailored to meet the unique needs of a specific client that are not addressed by the standardized care plan.
Documents Included in a Complete Plan of Care
- Problem list
- Kardex cards for client profile, basic needs, etc.
- Special discharge plan
- Special teaching plan
- Policies and procedures
- Protocols
- Standards of care
- Individualized NCP, listing the interventions and outcomes for the day
Guidelines for Writing Nursing Care Plans
- Date and sign the plan for evaluation, review, and future planning.
- Use category headings, such as "Nursing Diagnosis", "Goals/Desired Outcomes", etc.
- Use standardized medical or English symbols and keywords instead of complete sentences.
- Be specific about expected timing, such as "dressing q shift vs q 12h".
- Refer to procedure books or other sources of information and avoid including all the steps.
- Tailor the plan by incorporating the client's preferences and choices.
- Ensure the plan incorporates preventive, health maintenance, and restorative aspects (e.g., active assist in ROM to prevent joint contracture and maintain muscle strength).
- Ensure the plan includes interventions for ongoing client assessment (e.g., inspect wound q 8 hrs).
- Include collaborative activities (nutritionist, physiotherapist).
- Include plans for the client's discharge and home care needs (social workers, agencies, teaching).
The Planning Process
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Setting Priorities involves establishing a preferential sequence for addressing nursing diagnoses and interventions based on urgency:
- High priority (life-threatening, such as loss of respiratory or cardiac function)
- Medium priority (health-threatening, such as acute illnesses)
- Low priority (developmental needs)
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Factors to Consider When Setting Priorities:
- Client's health values and beliefs
- Client's priorities
- Resources available to the nurse and client
- Urgency of the health problem
- Medical treatment plan
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Description
This quiz explores the standards, protocols, policies, and standing orders involved in nursing care planning. Understand how these elements contribute to the development of effective care plans for clients with similar medical conditions. Test your knowledge on the key components that govern nursing actions and client care.
