Ward Class

An Online Resource Site For Student Nurses

Welcome

Ward Class is an online resource for student nurses. Created with the aim of helping student nurses cope with the demands of nursing school and clinicals, it offers free downloads, notes, sample NCPs, sample drug studies, study aids, news and updates, and practical tips to its users.

Site Announcement

The December 2012 PRC Nursing Board Exam Result is already available here at Ward Class and at Pinoy R.N.




The Nursing Care Plan (NCP)


Definition
  • the nursing care plan (or client care plan) is a written guide that organizes information about a client's care
  • the nursing care plan starts as soon as the client is admitted to the healthcare agency or hospital and is continually updated throughout the client's stay, in response to the changes in the client's condition and the client's responses to the nursing interventions rendered
  • types of nursing care plans:
    • preplanned/preprinted--> standardized guides for providing essential care to a specific group of clients with common needs
    • handwritten care plans
    • computerized care plans--> may also be adapted to client's specific needs
    • case management plans-- collaborative care plans; multidisciplinary care plans
Purposes of the Nursing Care Plan
  • Nursing Care Plans are written for the following purposes:
  1. To provide direction for individualized client care--> a nursing care plan is organized according to each client's unique needs; standardized care plans are also adapted to the client's needs and are used in combination with handwritten care plans as needed
  2. To provide for continuity of care--> the nursing care plan is a means of communicating and organizing the actions of the nursing staff; it is constantly updated and changes are communicated to all nursing staff during change-of-shift reporting (or during endorsement, if you are from the Philippines), nursing rounds, and client care conferences.
  3. To provide direction about what needs to be documented in the client's progress notes--> the nursing care plan specifies which observations to make, what actions to carry out, and what instructions the client or family members require; facilitates recording
  4. To serve as a guide for assigning staff to care for the client--> the nursing care plan facilitates delegation among nursing personnel
  5. To serve as a guide for reimbursement from medical insurance companies--> nursing care plans are often accessed by insurance companies for them to determine what they will pay in relation to what services the hospital rendered to the client; a nursing care plan is a documented proof of all nursing care rendered and simply put, "Nursing Care Not Documented is Nursing Care Not Rendered"
General Guidelines for Writing NCPs
  1. Date and sign the plan--> the planning or expected outcome portion is usually dated and signed as basis for evaluation of goal achievement (note: most clinical instructors require end-of-shift NCPs from students and may not require this)
  2. Use appropriate headings such as Assessment, Nursing Diagnosis, Planning, Nursing Interventions, and Evaluation (note: headings may vary per institution but the nursing process is always kept in mind)
  3. Use standardized medical or English key words to communicate your ideas-->e.g. turn and reposition client q2h (not turn and reposition client every two hours)
  4. Keep the care plan clear and concise
  5. Tailor the plan to the unique needs and characteristics of the client
  6. Ensure that the nursing care plan includes preventive, promotive, and restorative aspects of client's health
  7. Ensure that the plan provides for ongoing assessment of the client--> e.g. orders such as measure I&O q shift
  8. Include collaborative activities in the plan
  9. Include discharge planning and health teachings necessary for self-care--> shorter acute hospitalizations necessitate meticulous discharge planning
Note: Ward Class is currently in the process of making SAMPLE NCPs (using a 6-column format) for student nurses. Uploads will be done regularly. To receive automatic updates, please remember to subscribe to the mailing list located at the upper right corner of this site.

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