A care plan helps nurses and other care team members organize aspects of patient care at different stages of clients’ lives. It is a tool for health care professionals to think critically and holistically to support all aspects of a client’s life, including physically, psychologically, socially, and spiritually.
A Nexim staff will listen to the client and their family. They will ask questions and learn about the client’s needs. They will then take everything said and create a care plan that focuses on the client in a big-picture way. Care plans make sure clients get evidence-based, patient-centred care.
The care plan is written down for everyone to read. It ensures everyone is on the same page. A care plan usually includes:
- Assessment and diagnosis – this includes medical results and diagnostic reports. In addition, we will discuss the client’s physical, emotional, psychosocial, cultural, spiritual, cognitive, functional, age-related, economic, and environmental wants and needs.
- Outcomes – we will review the client and their loved one’s long and/or short-term expected outcomes.
- Interventions – this includes nursing interventions. Examples of interventions include drugs, movement, or assessing breathing or blood pressure.
- Rationales – we review the interventions and provide reasoning for them. Providing reasoning for interventions ensures care is evidence-based.
- Evaluation – here we document the outcomes. We may tweak the care plan after an evaluation.