Hello, my name is Laura, but you might know me as Nurse Killam on YouTube. I am excited
because today we are going to talk about care plans.
In this video I am going to give an overview of
Why we use care plans The components of care plans and
How they are connected to the nursing process
Care plans are so important for safe patient care. Basically a care plan is used to communicate
with the healthcare team what the plan of care is for a particular client is. It outlines
specific aspects of care so that important elements are not missed or neglected.
Some people seem to think that they are a waste of time or even try to ignore them,
but that is dangerous! Without a written care plan communication of client needs would suffer.
With all the different people working in the healthcare setting something would almost
certainly be missed and there could be legal consequences.
The amount of detail you put into your care plan will depend on where you are working.
In school, for example, we make you put more detail into a care plan than you will see
in the hospital because you are still learning the nursing process and how to care for clients.
In the work setting different organizations will abbreviate how the care plan is presented
but nurses still need to think through the entire nursing process when they are developing
care plans. Usually they are presented in a table format.
The care planning process parallels the nursing process. In fact, most care plans in school
will use the nursing process as the headings in the table you are using for your care plan.
They may or may not add in sections for rationales.
Before you put anything in writing you need to do an assessment of the client. Familiarize
yourself with the client’s previous assessments and records to gather information that will
inform you as you think critically about this person’s plan of care. Then make sure you
actually assess the person yourself. The type of assessment you complete will depend on
where you are working. Your organisation will have protocols for what types of initial and
ongoing assessments are needed. If you are in school you may be given a case study to
work with instead of an actual person.
After assessing the client you will need to formulate nursing diagnoses. Unless you are
very experienced and up to date on current best practices you will probably need to do
some reading to help you create complete and accurate nursing diagnoses. Diagnostic handbooks
can help you formulate nursing diagnoses. I also have a few videos on my channel that
can help you with this. Medical-surgical textbooks can help you learn about the client’s disease
and typical nursing diagnoses as well as care measures that you can include later in your
care plan.
In some settings you will see standardised care plans. These care plans are used as a
starting point for common situations that you will encounter on a particular unit or
in a certain setting. In order to be most effective these care plans should be individualised.
If you are starting from a standardised care plan now is where you would select one, but
keep in mind it is just a starting point. Be sure to read whatever information accompanies
it as it may help to guide some of your decision making.
If you are starting with a blank table now is when you would want to fill in the information
you have collected so far including the client’s name, medical diagnoses and your assessment
data. Typically instructors will ask you to separate subjective and objective assessment
data. Remember that Subjective information is Reported but not objectively measureable.
You cannot see it. It includes verbal descriptions of health. Subjective data are often referred
to as symptoms and represent things a client tells you about that you cannot observe or
measure. Most subjective data will be collected during a health history.
Objective Data on the other hand is measureable. Think about things like temperature, blood
pressure, and weight. Objective data are often referred to as signs. These signs can be seen
heard, felt, or smelled and are often collected during a physical exam.
If you are using a standardised care plan make sure you modify what they have so everything
in it applies to your client. Also be careful that you have included everything that you
need to in it.
Next you will want to modify or write your expected outcomes or desired outcomes or client
goals. The heading for this column may vary but it all mens the same thing. Make sure
that your outcomes are SMART. Make sure that the desired outcomes that are generated by
your computer or that you find in your textbook are SMART. S M A R T. Be careful because sometimes
they are missing pieces that need to be individualised. Remember that SMART means Specific, Measurable,
Achievable, Relevant and Time limited. Once, when I told a student that her outcomes were
not SMART (and yes, I used the capital letters) she thought I was talking about her brain
power, but I wasn’t! Its an acronym for Specific, Measurable, Achievable, Relevant
and Time limited. I have a video about smart goals on my channel if you want some examples.
Outcomes also need to be singular, patient centered and mutually determined. That means
that each goal needs to contain one action, be focused on the client and be created with
the client. Each goal should have a subject, verb, any needed conditions or performance
criteria and timelines. These goals are really important because they will guide what nursing
interventions you select.
Next, fill out the planning and implementation section of your care plan. This is where you
will what nursing actions or interventions need to be done in order to help the client
meet the outcomes you just created in collaboration with them. Like goals, you need to be sure
that interventions are clearly written. They should identify the date the action was added
to the care plan, who should be performing the task and what action needs to be done.
How, when, where, how often, how long or how much should the task be completed?
You should have baseline data from your assessment. Using this baseline data and your goals determine
what needs to be done to move the client towards their goal. Even though there are common interventions
for certain goals, interventions should be individualised to your client. The best way
to accomplish this is to involve the client in the planning process. Ensure that all interventions
are consistent with any other medical or treatment plans that exist. Use your critical thinking
to anticipate potential complications and monitor for them.
In school, we often ask our students to include rationales for their interventions in a separate
column. These rationales are numbered and correspond to the listed interventions. Basically
this is where you show your teacher that you know why you are performing an intervention.
Verbalize your understanding of the client’s individual situation. While there are a lot
of things you could consider in your rationales you need to be sure to be clear and concise.
Specify the most relevant rationale.
You will then have a column for your evaluation of the expected outcomes. Evaluation of the
care plan is an important step that sometimes gets missed. For each expected outcome ongoing
evaluation is needed to determine if your interventions are helping the client to achieve
their goals. If not, they need to be reassessed. Sometimes the outcomes will change. Other
times the interventions or time-frames will change. In school, some teachers want you
to simply state if the goals were met while others want you to describe what data you
are looking for or have found to evaluate your outcomes.
Thank you for watching. If you found this video helpful please like it and come on over
to my channel to find more videos like it. I started making videos because I was sick
of seeing students struggle to understand things in the classroom. Many people have
a hard time absorbing information during long lectures packed into 12 hours of classes.
I have found that YouTube is an excellent way to learn because you can explore what
you need to when you need to. I love using YouTube to help students understand the most
difficult parts of nursing school. Just let me know what videos would help you by commenting
on one of the videos on my channel and I will make them! Thanks again for watching and I
hope your care plans seems easier now.