The nursing process has an essential and tangible result: the nursing care plan, a detailed outline that guides the care delivery process. The care plan, like the nursing process, includes several steps that the nurse uses to formulate the direction of care. These are the nursing diagnosis, the expected outcomes, the interventions and the evaluation. Interventions are actions taken by the care manager to achieve the patient's goals and obtain the desired results.
The most common interventions include educating the patient, administering medications, monitoring vital signs regularly, or evaluating the patient's pain levels at certain intervals. Dependent nursing interventions are interventions that depend on the request or order of another discipline. Most commonly, these are doctor's orders or permanent medical protocols. These interventions include more advanced care, such as medication administration, wound care, formula feeding, such as a catheter, and advanced treatment for going to the bathroom, such as urinary catheters or bowel control systems.
The action part of the SOAIP note would detail the interventions carried out to care for the patient and, although they may not use the exact language of the NIC, those actions can be linked to the classifications. Nursing interventions are the action steps of the nursing process, the time when the nurse intervenes or provides various types of care to the patient. Care plans help nurses focus on patients in a holistic and global way so that they can provide evidence-based, patient-centered care. Nursing interventions include everything that nurses do directly with patients and things that are done on behalf of patients, which improves patient outcomes.
The purpose of a nursing care plan is to document the needs and wants of the patient, as well as the nursing interventions (or implementations) planned to meet these needs. Examples of indirect care interventions include attending care conferences, documenting and communicating patient care with other providers. Some of the interventions you can use most frequently include pain management, position changes, preventing falls, ensuring adequate fluid or calorie intake, controlling the sleep pattern, or involving the patient in mobility therapy. Care plans are used to teach nursing students how to individualize patient care, think critically about what is needed to achieve desired outcomes, and work to achieve those outcomes through the nursing process.
A care plan helps nurses and other members of the care team organize aspects of patient care according to a schedule. Provider interventions may also include office redesign work that analyzes changes in the system within an office to support better care guidelines and evidence-based practices. While all nursing programs teach the basics of writing a care plan, the program you attend will shape your communication, goal-setting and critical thinking skills. Ensuring high-quality education for family members about patient procedures and needs at home is an essential part of nursing intervention.
Even if your hospital requires care plans, unless it's a strict requirement, there's a good chance that nurses aren't preparing one for every patient because they're too busy. Finding these resources isn't always intuitive, but with a little help from the IT department, you can create personalized care plan forms that are part of each patient's registry and each nurse's workflow.
