NURSING CARE PLANS

Excellent nursing practice reflects proficient use of the nursing process demonstrated by skillful assessment, diagnosis, planning, outcome identification, intervention, and evaluation. The nursing process provides the framework that directs nursing practice. Nursing care planning is the application of the nursing process to a specific client situation. Written nursing care plans are a means of communication among health care providers, clients, and families. They ensure that care is coordinated to achieve desired health care outcomes.
A thorough assessment is the foundation of the nursing process. The assessment data are then reviewed and organized according to client needs. Nursing diagnoses, derived from the assessment, provide the basis for selection of interventions to achieve outcomes for which the nurse is accountable (NANDA, 2003). “Now, as never before, today’s nurse must make more complex professional decisions, determine what things to do and what things not to do for which clients. Priorities are critical: often the nurse must make hard choices between what is essential and what is merely beneficial” (Barnum, 1999). The primary purpose of the nursing diagnostic processes applied by nurses is to design a plan of care for and in conjunction with the client that results in the prevention, reduction, or resolution of the client’s health problem (Harkreader, 2004).
In the current multidisciplinary health care environment, nurses are positioned for a high level of accountability. The nurse is required to make many independent decisions and to coordinate the various disciplines working together and sharing responsibility for client outcome achievement. This environment affords nursing an opportunity to define its boundaries and to use the nursing process to coordinate care across disciplines. Nurses need to develop strong assessment skills, organize the data obtained to prioritize client needs, predict achievable, measurable client outcomes, and tailor interventions for the individual client.