Nursing Care Plan
A care plan includes the following components;
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Client assessment, medical results and diagnostic reports. This is the first step in order to be able to create a care plan. In particular client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic and environmental. Information in this area can be subjective and objective.
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Expected patient outcomes are outlined. These may be long and short term.
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Nursing interventions are documented in the care plan.
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Rationale for interventions in order to be evidence based care.
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Evaluation. This documents the outcome of nursing interventions
A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. Using electronic devices, nursing care plans became more accurate, accessible, easier completed and easier edited, in comparison with handwritten and preprinted care plans.
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