Components of the Plan of Care

The plan of care is designed to be a client-centred, action-orientated document which outlines the following components;

COMPREHENSIVE NURSING ASSESSMENT

A comprehensive assessment identifies the needs, preferences, and abilities of the client and includes a physical and psychosocial assessment. Assessment is used to determine the client’s presenting signs and symptoms, the client’s psychosocial status using the determinants of health. The data and information gathered and analyzed to determine a nursing diagnosis.

Some organizations use an admission data base as the tool used by nursing to complete the comprehensive assessment. Although this tool may seem long, the collection of this information on admission will inform the development of a plan of care which results in an efficient use of resources. For example, consideration of the clients’ home environment and financial status is required to develop an appropriate discharge plan.

If your organization does not have an admission database tool, you may want to discuss developing a tool with your manager. There are many examples of various types of admission databases which focus on specific populations. A search of the internet will provide you with examples of these tools.

Health is determined by complex interactions among social and economic factors, physical environment and individual behaviors, which do not exist in isolation from each other (Canadian Council of Social Determinants of Health, 2013). These determinants of health are essential in the comprehensive nursing assessment.

NURSING DIAGNOSIS

Nursing diagnosis is based upon the human response to a condition or disease and helps the RN determine the focus of nursing care to be provided to a client. Nursing diagnosis can also be referred to as focus areas or priority areas. The diagnosis reflects an issue or state of health to direct the plan of care that falls within the nurse’s scope of practice. Nursing diagnosis may include the client, family, or community. Nursing diagnoses are based on data obtained during the comprehensive nursing assessment.

Most nurses would be familiar with the North American Nursing Diagnosis Association (NANDA). It is not required by CRNNS that this format be used in the plan of care; it is required however that the nursing component of the clients plan of care has a nursing diagnosis. The employer will determine the format of the plan of care, which will include the nursing diagnosis. An example of a nursing diagnosis for a client admitted for a total joint replacement could be; Acute pain related to total knee replacement surgery

GOAL OF THE PLAN OF CARE

Goals and expected outcomes are specific client behaviors or physiological responses that the registered nurse and the client set to achieve (Potter & Perry, 2010). They provide a clear focus for the types of interventions necessary for client care and provide a focus for evaluation of the interventions. (Potter & Perry, 2010). Clients need to be able participate in setting goals; unless goals are set mutually and there is a clear plan for action, clients may not follow the plan of care. Goals and outcomes need to be relevant to the client needs and be specific, observable, measurable, and time limited (Potter & Perry, 2010).  Some examples of a client-centered goal for a client admitted for a total joint replacement could be;

• Client’s self report of pain will be 3 or less on a scale of 0 to 10.

• Client will be able to mobilize with minimal discomfort (pain scale of 3 or less).

NURSING INTERVENTIONS

Nursing interventions are actions carried out by a nurse to implement the nursing plan of care. The development and implementation of interventions are individually based on the nursing assessment and are developed in consultation with the interprofessional team, including the client.

There are three types of nursing interventions: a) nurse initiated, b) physician initiated, and c) collaborative (Potter & Perry, 2010).

a. nurse initiated interventions are independent nursing interventions; they do not require orders or direction from another health care professional. An example of an independent nursing intervention is directing a client to splint an incision during coughing post-operatively.

b. physician initiated or dependent nursing interventions are those that require orders or directions from physicians or other health professionals. The interventions are directed toward treating or managing a medical diagnosis. The RN intervenes by carrying out the written or verbal orders. An example of a dependent nursing intervention is the administration of medication or changing a dressing.

c. collaborative interventions or interdependent nursing interventions are interventions that require the combined knowledge, skill, or expertise of a number of health care professionals. Interdisciplinary health care team conferences are helpful in determining interdependent nursing interventions. An example of a collaborative intervention is a nursing consultation with the unit social worker to help prepare the client for discharge.

EVALUATION

Evaluation is an ongoing process, of reviewing subjective and objective data from the client, family and other health care team members(Potter &Perry, 2010). The RN also reviews information regarding the client’s current condition treatment, resources available for recovery and the expected outcomes. During the evaluation, the RN makes clinical decisions and continually redirects nursing care. For example, when the RN evaluates the client pain severity, the RN applies knowledge of the disease process, physiological response to interventions and the correct procedure for pain severity measurement to interpret whether a change has occurred and whether the change is desirable.

Evaluation leads to either the discontinuation of the plan of care or a revision to the existing plan of care (Potter & Perry, 2010). If the client meets all the established goals and are in agreement with the discontinuation of the plan of care then that specific portions of the plan of care may be discontinued. When goals are not met, the plan of care will need to be mutually revised with the client making changes to goals and interventions as appropriate to develop a more realistic plan for the client.

References

Canadian Council of Social Determinants of Health. (2013). Communicating the social determinants of health; Guidelines for common messaging. Retrieved from http://ccsdh.ca/ on May 12, 2015.

College of Licensed Practical Nurses of Nova Scotia, College of Registered Nurses of Nova Scotia. (2012). Effective Utilization of RNs and LPNs in a Collaborative Practice Environment. Halifax, NS: Author.

College of Licensed Practical Nurses of Nova Scotia (2013). Guidelines for licensed practical nurses in Nova Scotia; The professional practice series; The nursing care plan. Halifax, NS:Author.

College of Registered Nurses of Nova Scotia. (2013). Entry-level competencies for registered nurses in Nova Scotia. Halifax, NS: Author.

College of Registered Nurses of Nova Scotia. (2017). Standards of practice for registered nurses. Halifax, NS: Author.

Potter, P.A. & Perry, A.G. (2010). Canadian Fundamentals of Nursing. Fourth Edition Mosby Toronto, ON, CA.

Registered Nurses Act, c. 21. (2006). Statutes of Nova Scotia. Halifax, NS: Government of Nova Scotia.