Formats of a Nursing care plan

Formats of a Nursing care plan

Johnson (1959), Orlando (1961), and Wiedenbach (1963) have developed a three-point nursing care plan i.e. assessment, planning and evaluation. In their 1967 book The Nursing Process, Yura and Walsh identified four steps in the nursing care plan i.e. Assessing, Planning, Implementing, and Evaluating. Fry (1953) first used the term nursing diagnosis, but it was not until 1974, after the first meeting of the group now called the North American Nursing Diagnosis Association (NANDA), that Gebbie and Lavin added nursing diagnosis as a separate and distinct step in the nursing process. Prior to this, the nursing diagnosis had been included as a natural conclusion to the first step, assessment. Following the publication of the ANA standards, the nurse practice acts of many states were revised to include the steps of the nursing process specifically. The ANA made revisions to the standards in 1991 to include outcome identification as a specific part of the planning phase. Currently, the steps in the nursing process are:

• Assessment
• Diagnosis
• Outcome identification and planning
• Implementation
• Evaluation

Components of a care plan

A nursing care plan generally includes assessment, diagnosis, goal, intervention, rationale and evaluation. Elaboration of these components is given below:

Assessment: This is the first step towards preparing a nursing care plan. In this nurses collect various information like demographic data, present history, past history, medical and surgical history, and also including emotional, sexual, social, and cultural areas of the patient. Information may be subjective (what is said by the patient and relatives) or objective (what the nurse observes). Diagnosis: Nursing diagnosis is done considering the actual and potential problems of the patient. It is written according to the NANDA diagnosis. Goal: It is the desired solution to the problem of the patient. Planning: Planning is listing out the measures to be taken for the patient. Interventions: These are the actions of the nurses to solve the problem. Rationale: It describes the scientific and evidence-based care of each step. Evaluation: End result of the nursing activity. If the goal is achieved then the process stopped, if the desired goal is not achieved then again the whole process is repeated with modification.

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