Making a plan for nursing care may not be difficult for you. However, making that plan actually work is where you face difficulty. Although you know exactly what your patient requires from you, you still face difficulties in finding the way to prioritise and coordinate your efforts with those of other health professionals.
A single mistake or neglecting one of the stages may affect the level of care provided to your patient. But once you have a well-designed plan at hand, implementing it becomes much easier. Let’s see how it should be done.
What Is Executing a Nursing Care Plan?
Executing a nursing care plan is all about putting the interventions included in the nursing care plan into practice to meet the healthcare needs of the patient and control their symptoms. It is not enough to complete a series of actions while executing a nursing care plan.
It is essential to know why these measures were taken. In most cases, the nursing care plan consists of five consecutive steps:
- Assessment: It involves the collection of information regarding the state of health, symptoms, history and any other problems of the patient.
- Diagnosis: Here, the nursing problems are diagnosed from the results of assessment.
- Planning: It involves planning goals and interventions.
Whereas implementation is the point where the plan is implemented, the other points are still very important. Any new symptoms, variations in vitals, or a strange reaction to any form of treatment can make one return to the stage of assessment.
How to Carry Out Planned Nursing Interventions Safely?
Having completed prioritisation, start implementing those interventions that have been made by you, taking into consideration your responsibilities and competence as well as the needs of the patient. Make sure that you follow all the guidelines, maintain hygiene, and respect the dignity of the patient.
The specifics of your actions will depend on the patient’s condition. Among the possible interventions are:
- Measurement of vital signs and notification of any changes.
- Wound care according to the treatment plan.
- Helping with moving, hygiene, nutrition and hydration.
- Prescribing medications according to your role.
- Supporting patients with pain management and comfort measures.
- Patient education regarding their condition and needs for treatment.
It is important to ensure patient participation throughout the process. Ask how much the patient hurts, explain procedures that are unfamiliar to them, and take into account patient preferences where it is possible. Where a patient rejects an intervention, discuss their objections and follow the right clinical process.
Why Is Documentation Essential When Executing a Care Plan?
Documentation ensures that there is a proper record of the care provided, the patient’s response, and anything that might need further attention. This will assist other health professionals in understanding what has happened.
After the intervention, make records of all relevant information based on your workplace policy. They could be:
- The care or treatment offered and time of provision.
- The observations of the patient and the patient’s response.
- Anything strange, unexpected, or a change in the condition of the patient.
- Communications with other health professionals.
- The actions taken, referrals made, and any follow-up needs.
As an example, documentation that the patient was helped in walking is less detailed compared to documentation about how much help was given, how far they walked, and how difficult it was for them.
How to Evaluate Whether the Care Plan Is Working?
The implementation of the care plan does not conclude after implementing all the interventions listed. The care plan should be evaluated to check if the desired outcome has been achieved and the patient’s requirements have remained the same.
The patient’s condition can be compared to the objectives set earlier during planning. If the objective was improvement of the ability to move, then it should be seen if the patient is moving better and requires less assistance now.
Evaluation would result in one of the following actions:
- Objective achieved: Continue giving appropriate care and start planning the next steps.
- Objective partially achieved: See what works well and what needs further attention.
- Objective not achieved: Re-evaluate the patient, check for any obstacles, and revise the plan with appropriate healthcare professionals.
Just because nothing has happened does not mean that the intervention was unnecessary. Time may be needed for recovery, and the patient’s state could have changed, as well as other factors being at play.
What Common Mistakes Should You Avoid?
Even the most effective care plan can be made useless because of the absence of consideration of certain common elements. These considerations will give you more effective care. The common mistakes that you should avoid include:
- Failing to review the care plan: The needs of the patient will keep on changing from time to time during the shift.
- Use of confusing instructions: Any confusion must be cleared first before implementing an intervention.
- Late documentation: Inaccurate documentation may cause information gaps for your colleagues.
- Disregarding patient’s preference: Consider the preferences of the patients in the process of decision-making.
- Failure to notify about any concerns: Communicate any change in condition or any issue without delay.
With the continued use of the unsuccessful intervention strategy, evaluate progress and follow the required guidance. In case you find it difficult to link the assessment findings to the diagnosis and interventions in nursing, you can consider using nursing clinical cases and seek nursing case study assignment help.
How Nursing Students Improve Care Plans?
First of all, when it comes to nursing students, the creation of a care plan begins with the awareness of the patient’s case and making use of assessment data to develop nursing interventions. In simple terms, it will require you to use your classroom knowledge by using your critical thinking skills as opposed to memorising the standard format.
In nursing care plan writing practice, there are three main factors that should be considered. These include identifying the priority needs of the patient, having measurable goals, and describing how each intervention solves a certain problem.
The method that can be employed in practising writing a nursing care plan is analysing the case of a patient who has diabetes. Some possible concerns in this case may involve blood sugar control, medication administration, foot care, and education of the patient.
Readers Usually Ask
Which is the key element during the implementation of care plans?
It is crucial that patient safety and continuous assessments be some of the most important factors while implementing the care plan.
How frequently should the care plan be evaluated?
The answer depends on the client’s condition, the setting where he or she receives nursing care, the objective of the evaluation, and any relevant laws.
Is it possible to change a care plan after its implementation?
Yes. It is necessary to update your care plan based on the results of the re-evaluation if something has changed in terms of the patient’s needs, risks, or state.
What is the difference between implementation and evaluation of a care plan?
While implementation is the process of performing the intervention, evaluation means looking at the patient’s reaction and making sure that the desired outcome is reached.
In Conclusion!
For a care plan to be effectively implemented, it is necessary to plan, have clinical judgement, good communication skills, and evaluate. Each step of a care plan must be linked to a certain need of the patient, made according to all safety measures, and directed towards getting a positive result. By dealing with the most urgent issues first, you will notice arising issues and change your care plan accordingly.
If you are a practising nurse or a nursing student who is working on developing clinical skills, keep in mind that care plans should be viewed not as a rigid checklist but as a flexible tool which should take into account the patient’s needs.
