Planning Nursing Care II

An informal nursing care plan is an action in the nurse's mind, used for individual shift goals and not included in the patient chart. A formal nursing care plan is a written or computerized blueprint for patient care that organizes care systematically. Formal plans are further divided into standardized care plans for routine patient needs and individualized care plans tailored to unique patient needs.

The five formats include computerized care plans, which reduce paperwork and enhance record keeping through electronic medical records. Change of shift reports communicate information during nursing handover. Critical pathways provide standardized multidisciplinary plans with predicted outcomes within timeframes. Concept mapping graphically organizes patient data and relationships for a holistic health view. Student care plans help apply nursing literature knowledge and are more elaborate than hospital care plans.

Maslow's Hierarchy of Needs aids in prioritizing nursing diagnoses and subsequent interventions based on patient needs. The nurse develops nursing diagnoses according to data collected during assessment, then uses this framework to determine which diagnoses require immediate attention. This ensures interventions address the most critical patient needs first.

SMART goals are Specific, Measurable, Achievable, Relevant, and Time-Bound objectives created after selecting a diagnosis. These goals must align with patient desires and realistic circumstances. For example, if a patient prioritizes mental health over dietary choices, the care plan should reflect patient-centered goals rather than nurse-assumed priorities.

Implementation is when nursing interventions outlined in the care plan are executed. Some interventions show immediate results, while others may only be visible later in the shift or hospital stay. The nurse carries out the planned actions to address the patient's identified needs and work toward established goals.

Evaluation allows the nurse to assess intervention outcomes and determine if goals were met. SMART goals have three possible outcomes: met, ongoing, or not met. Based on evaluation results, the nurse decides whether goals and interventions need adjustment as the patient's care journey evolves.

Standardized care plans are pre-populated guides for specific patient populations, such as post-operative patients, specifying routine nursing care. Individualized care plans are tailored to each patient's unique needs and adjust as the patient care journey evolves. Both types are formal written or computerized plans that organize patient care systematically.