Monday, November 24, 2008

How To Create A Nursing Care Plan

How To Create A Nursing Care Plan base on
Standards of Practice
Describes a competent level of nursing care as demonstrated by the nursing process  that encompasses all significant
actions taken by the nurse in providing care and forms the foundation of clinical decision making.

  1. Assessment:The registered nurse collects comprehensive data pertinent to the patient’s health or situation.
  2. Diagnosis:The registered nurse analyzes the assessment data to determine the diagnoses or issues.
  3. Outcome Identification:The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
  4. Planning:The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
  5. Implementation:The registered nurse implements the identified plan.
  • Coordination of Care:The registered nurse coordinates care delivery.
  • Health Teaching and Health Promotion:The registered nurse employs strategies to promote health and a safe environment.
  • Consultation:The advanced practice registered nurse and the nursing role specialist provide consultation to influence the identified plan, enhance the abilities of others, and effect change.
  • Prescriptive Authority and Treatment:The advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.
6. Evaluation:
  • The registered nurse evaluates progress toward attainment of outcomes.
Standards of Professional Performance
Describes roles expected of all professional nurses appropriate to their education, position, and practice setting.
  • Quality of Practice:The registered nurse systematically enhances the quality and effectiveness of nursing practice.
  • Education:The registered nurse attains knowledge and competency that reflects current nursing practice.
  • Professional Practice Evaluation:The registered nurse evaluates one’s own nursing practice in relation to professional
    practice standards and guidelines, relevant statutes, rules, and regulations.
  • Collegiality:The registered nurse interacts with and contributes to the professional development of peers and
  • Collaboration:The registered nurse collaborates with patient, family, and others in the conduct of nursing practice.
  • Ethics:The registered nurse integrates ethical provisions in all areas of practice.
  • Research:The registered nurse integrates research findings into practice.
  • Resource Utilization:The registered nurse considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.
  • Leadership:The registered nurse provides leadership in the professional practice setting and the profession.
Source: American Nurses Association. (2004). Nursing: Scope & Standards of Practice. Silver Spring, MD:
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