Nursing care plans assist nurses in concentrating on patients more comprehensively and all-encompassing, enabling them to provide evidence-based and patient-centred care. In addition, care plans assist hospitals in maintaining continuity of care during nursing shifts, fostering inter-professional teamwork by ensuring that all parties involved are on the same page, and satisfying documentation requirements imposed by regulatory bodies and insurance providers. In the information below, we focus on nursing care plans and will present you with nursing care plan goals, how to write a nursing care plans paper, and most importantly, nursing care plan examples.
Nursing Care Plans
A nursing care plan, or NCP, is a structured procedure that accurately identifies current needs and recognizes any potential needs or dangers. Care plans improve patient outcomes by facilitating communication between nurses and their patients and nursing professionals. The nurse care planning process enables patients to receive consistent, high-quality care during their episodes of care.
Nursing care planning starts when the patient is admitted to the facility and is regularly revised in response to the patient’s shifting conditions and assessments of their level of attainment of their goals during their stay. The foundation of exceptional nursing practice is the planning and execution of personalized care, sometimes known as patient-centred care.
Nursing Care Plans Goals
When drafting a nursing care plan, it is essential to keep in mind the following aims and objectives:
1) Foster nursing care is supported by research and strives to make medical facilities, such as hospitals and health centres, more welcoming and comfortable.
2) In treating and preventing illness, it is essential to consider all aspects of a patient’s well-being, including the physical, psychological, social, and spiritual aspects of their lives.
3) Create initiatives like care pathways and care packages to improve patient care.
4) To get to an agreement about the standards of care and anticipated results, care pathways need the participation of a team.
5) On the other hand, care packages are connected to the best practices for the care offered for a particular illness.
6) Determine and differentiate between your objectives and the anticipated results.
7) Consider the effectiveness of the care plan’s communication and documentation.
8) Measure nursing care.
How To Write a Nursing Care Plans?
How exactly does one go about writing nursing care plans? To create a care plan for your client, follow the steps below.
1) Accumulation of Information or Evaluation
Creating a client database using various assessment strategies and data gathering procedures is the first stage in producing a nursing care plan (physical assessment, health history, interview, medical records review, diagnostic studies). All the collected health information is stored in a client database. During this stage, the nurse can determine the associated or risk factors and the defining qualities that may be used in constructing a nursing diagnosis. You may be able to employ specialized evaluation forms at some organizations or nursing schools.
2) Organizing and analyzing the data
Once you have information on the client’s health, you may evaluate, group, and arrange the data to develop your nursing diagnosis, priorities, and intended results.
3) Constructing your nursing diagnoses
Nursing diagnoses from the NANDA are standardized approaches to recognizing, concentrating on, and responding to the unique requirements of individual clients who are experiencing genuine or high-risk issues. Nursing diagnoses refer to the actual or future health issues that may be averted or remedied with the assistance of independent nursing intervention.
4) Establishing Your Top Priorities
A recommended order for attending to nursing diagnoses and interventions is defined as setting priorities. During this process phase, the nurse and the client will work together to determine which nursing diagnosis has the highest priority. The severity of a patient’s diagnosis may be rated, and it can also be categorized as either high, medium, or low priority. Issues that might result in loss of life need to be addressed immediately.
A nursing diagnostic considers Maslow’s Hierarchy of Needs and assists in organizing and planning treatment following patient-centred outcomes. Abraham Maslow devised a hierarchy in 1943 that was based on the basic fundamental needs that are natural to all persons. Before achieving higher wants and goals, such as self-esteem and self-actualization, one must fulfil one’s essential physiological requirements and objectives. The provision of nursing care and the performance of nursing interventions are predicated on the patient’s physiological and safety requirements. As a result, they are located at the bottom of Maslow’s hierarchy and are responsible for setting the groundwork for both physical and mental well-being.
The Needs Based on the Hierarchy of Maslow
• Nutrition (water and food), elimination (toileting), airway (suction), breathing (oxygen), and circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep, sex, shelter, and exercise are the fundamental requirements for maintaining one’s physiological health.
• Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), cultivating an environment of trust and safety (the therapeutic relationship), and patient education are all aspects of safety and security (modifiable risk factors for stroke, heart disease).
• Love and Belonging: Cultivate Loving Relationships, Find Ways to Avoid Social Isolation (Bullying), Practice Therapeutic Communication and Sexual Intimacy, Active Listening Techniques, and More!
• Acceptance in one’s community and place of employment, personal accomplishment, a feeling of control or empowerment, and an acceptance of one’s physical appearance or bodily habitus are all components of self-esteem.
• Self-Actualization includes having an empowering environment, growing spiritually, being able to perceive and appreciate the perspectives of others, and realizing one’s full potential.
• When determining priorities, the nurse must consider several elements, including the client’s health beliefs and values, available resources, and the level of urgency. Include the customer in the process to encourage more collaboration from them.
5) Establishing the Client’s Goals and Desired Outcomes
Following establishing priorities based on your nursing diagnosis, the client and the nurse will collaborate to establish objectives for each of the prioritized areas. What the nurse aims to accomplish by using the nursing interventions generated from the client’s nursing diagnosis is described as the goals or intended outcomes of the nursing care plan.
The client and the nurse can determine which issues have been resolved, which problems were resolved, and goals help motivate the client and the nurse by providing a sense of achievement. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, and enable the client to determine which problems have been resolved.
Selecting Appropriate Nursing Interventions
Nursing interventions are any activities or actions a nurse carries out to assist clients in achieving their objectives. The nursing diagnosis should be the primary focus of the adopted interventions to eliminate or significantly reduce the aetiology. Concerning nursing diagnoses associated with risk, actions need to centre around mitigating the client’s various dangers. Nursing interventions are recognized and documented at this phase of the nursing process; however, the step in which they are carried out is known as the implementation step.
Different nursing care plans diagnoses interventions, and outcomes
Independent, dependent, or collaborative care delivery are viable options for nursing care plan diagnosis interventions.
• Independent nursing interventions are any activity a registered nurse has the authority to initiate based on their superior knowledge and abilities. Included are ongoing assessments, offering emotional support and comfort, providing education and instruction, providing physical treatment, and referring patients to other health care specialists.
• Nursing interventions dependent on a physician’s instructions or supervision are actions the nurse carries out. Contains instructions for the nurse to provide drugs, intravenous therapy, diagnostic tests, therapies, food, and exercise or rest, as directed by the physician. The assessment and the provision of explanations when medical instructions are being carried out are components of the dependent nursing interventions.
• Interventions carried out in partnership with other healthcare team members, such as doctors, social workers, nutritionists, and therapists, are collaborative interventions. Nurses are responsible for carrying out these activities. These activities collaborate with other medical experts to get those individuals’ professional perspectives.
Nursing interventions ought to be in the following way;
• Protective and suitable for the patients’ age, state of health, and circumstances.
• Attainable given the time and resources that are now available.
• Following the ideas, values, and culture of the customer.
• Consistent with other treatments.
• Based on the nursing profession’s expertise, experience, or the information gained from other relevant scientific fields.
Take into consideration the following while developing nursing interventions:
• Please put the date on the plan and then sign it. The date the plan was put down is significant for evaluating, reviewing, and preparing for the future. The signature of the nurse is evidence that responsibility was met.
• Nursing interventions should be explicit and articulated, with each intervention starting with an action verb that indicates what is expected of the nurse. For instance: “Educate parents on how to take their child’s temperature and warn them of any changes,” or “Assess urine for colour, volume, odour, and turbidity.”
• Only the abbreviations recognized by the institution should be used.
6) Providing a Rationale
Rationales, sometimes called scientific explanations, provide the reasoning for selecting the nursing intervention for the NCP. Regular care plans do not provide rationales for their decisions. They are presented to aid nursing students in linking the pathophysiological and psychological concepts with the chosen nursing intervention, which is why they are included in the material.
Regular care plans do not provide rationales for their decisions. They are presented to aid nursing students in linking the pathophysiological and psychological concepts with the chosen nursing intervention, which is why they are included in the material.
7) Evaluation
Evaluating is a planned, continuing, and deliberate action in which the client’s progress towards accomplishing objectives or intended outcomes and the nursing care plan’s success is considered (NCP). Because the findings from this phase decide whether the nursing intervention should be cancelled, maintained, or adjusted, evaluation is a vital part of the nursing process.
8) Putting it Down on Paper
The treatment plan for the patient is recorded following hospital regulations. This documentation becomes part of the patient’s permanent medical record, which the incoming nurse may go through. The various nursing schools use various care plan forms. Most schools are organized in a five-column structure and are created in a way that students are guided in an orderly fashion through the interconnected stages of the nursing process.
Nursing Care Plans Examples
The following are examples of nursing care plans;
Postpartum Nursing Care Plans
What exactly constitutes a postpartum plan?
A postpartum plan is a collection of preferences for the first few weeks and months following your child’s birth. These preferences might include choices about parental leave, feeding, sleep, home tasks, self-care, and issues related to mental health.
Diabetic Nursing Care Plans
Patients who have diabetes are at risk for developing several other nursing diagnoses, the first of which includes conditions related to fluid balance and nutrition. Even if a patient with diabetes consumes an adequate number of calories daily, the body will still essentially starve if there is no way to transport the sugar consumed into the cells to be used as fuel. This is because diabetes impairs the body’s ability to regulate blood sugar levels within the cells. Therefore, we will go into the nursing diagnosis for diabetes that centres on nutritional deficiencies and fluid imbalances.
Tia Nursing Care Plans
What does it mean when a nurse diagnoses a TIA?
Nursing Diagnosis: Intolerance to exercise due to transitory cerebrovascular impairment and transient musculoskeletal weakness due to TIA, as seen by anomalies in blood pressure or heart activity in response to activity, easy fatigability, and widespread body weakness.
Psychosocial Nursing Care Plans
According to the opinions of the nurses, providing psychosocial care includes holistic treatment, spiritual care, support to the patient and their family members, and demonstrating empathy for the patient. In addition, communication is an essential part of psychosocial care, and it takes place not just between nurses but also between nurses, the patient, and members of the patient’s family.
Nursing Care Plans for Pneumonia
The nursing interventions for pneumonia and the care plan objectives for pneumonia patients include making efforts to aid in efficient coughing, keeping a patent airway, reducing the viscosity and tenaciousness of secretions, and providing assistance with suctioning.
Hospice Nursing Care Plans
Patients nearing the end of their lives may get holistic care that addresses their medical, psychological, social, and spiritual needs via end-of-life nursing care plans. Although some hospice services are provided in inpatient facilities, most of these programs allow terminally ill patients to receive care in their homes’ familiar and stress-free environment. The purpose of the hospice care team is to assist the patient in leading as pain-free and comfortable a life as possible, with as few limitations imposed on them as feasible.
In addition, it emphasizes the coordinated efforts of a team to assist the patient and their family members in overcoming the intense anxiety, fear, and melancholy that are common symptoms of a terminal disease. To achieve this goal, hospice staff encourage family members to assist with and participate in patient care. In doing so, they can provide the patient with comfort and security while assisting the family caregivers in beginning the grieving process even before the patient passes away.
Nursing Care Plans Atrial Fibrillation
The following nursing diagnoses are included in the care given to patients who have lone atrial fibrillation as part of their nursing treatment:
• Anxiety
• Reduced tolerance for physical activity
• Reduced amount of blood pumped by the heart
• Nursing Intervention Based on a Diagnosis
When a patient goes through the paroxysmal beginning of lone atrial fibrillation, they may experience anxiety and fear. Because the patient fears the development of a dysrhythmia that might be life-threatening, the patient may refuse to engage in the treatment being provided, need continuous attention, or ask inappropriate questions.
• Determine the patient’s capacity to cope with the circumstances and coping mechanisms.
• Assist the patient in determining what the issues are.
• Educating the patient on the medical diagnosis, including the symptoms, therapy, and the pathophysiology of cardiovascular disease is essential.
• Relaxation methods.
• Reduced Levels of Activity Tolerance is a condition that may develop as a result of syncope or vertigo brought on by a reduced cardiac output.
• Determine your current cardiac state before beginning the exercise. A baseline state may be determined by taking vitals before the activity.
• Monitor and record the patient’s activity tolerance.
• Check to see whether your dysrhythmias worsen while doing physical activities.
• Reduced Cardiac Output is due to the absence of the atrial “kick,” which occurs when an individual has atrial fibrillation. Reducing blood pressure, chest discomfort, and shortness of breath will be some of the symptoms.
• Maintain constant EKG monitoring.
• Analyze the vital signs and make a record of any physical symptoms.
• Keep at least one patent in good standing.
• Supplemental O2.
• Make sure you are ready for cardioversion.
Nursing Care Plans for Hypertension
In the case of hypertension, the aims of nursing care planning include bringing the patient’s blood pressure under control, adhering to the prescribed treatment, making appropriate changes to one’s way of life, and avoiding problems.
Nursing Care Plans for Depression
Strategies such as stress management, self-coping skills, relapse prevention, and psychoeducation are all included under the umbrella term “psychosocial treatments.” In addition to this, they contain psychological treatments such as cognitive-behavioural tactics or motivational interviewing approaches.
Nursing Care Plans for Copd
The most prominent sign of COPD is shortness of breath caused by a blockage in the airways. Patients should undergo examination and treatment as soon as possible since it may be scary.
Sample Nursing Care Plans
Nursing Assessment for Impaired Dentition
These are the nursing evaluation signals for impaired dentition that you should look out for. Make use of the advice that is provided below to construct your evaluation results.
| Assessment
|
Rationale |
|
Examine the patient’s oral hygiene routine.
Examine the colour, moisture, texture, irritation, and infection of the gums, teeth, and mucous membranes, particularly the tongue. Use a wet tongue blade with padding to gently draw the gums, cheeks, and lips back.
Determine the patient’s level of nutritional health.
Determine how well dental equipment suit your mouth.
Check for dryness in the mouth and smell the patient’s breath.
Determine whether or not the patient can do routine dental care.
Assessing the potential for monetary issues to boost oral hygiene maintenance efforts.
Listen for any reports of discomfort in the teeth.
Examine the degree to which the common phobia, known as “dental phobia,” contributes to a lack of dental care. |
Oral hygiene information instructs likely etiological variables and suggestions for further education.
When exposing parts of the oral cavity for examination, a tongue blade is recommended.
Poor dietary decisions might bring on issues with teeth. Inadequate dentition may affect the amount of food consumed since persons who have lost teeth tend to consume fewer foods high in fibre, such as fruits and vegetables.
An evaluation may indicate plausible reasons and assist patient education.
It is essential to have an average flow of saliva to keep the teeth clean. Halitosis may be caused by several factors, including dentition, dry mouth, and even medical conditions.
Patients may want help to finish their dental care.
Patients could feel too embarrassed to ask for help, or they might not be aware of the community resources that are accessible to them.
The development of dental caries and abscesses is prevalent and may be excruciating; as a result, dental examination and evaluation are required.
Patients can have had unpleasant past dental check experiences, and they might be anticipating that their next dentist visit will be painful. It’s possible that reducing fear may assist when you provide factual facts. |
Conclusion
Nursing care plans must encourage efficient communication among nurses if they are of any utility. They must be able to be shared, readily accessible, and constantly brought up to date. This implies that they need to be in electronic form and ideally linked into the EHR so that cloud storage can be accessed and real-time communication between professionals may occur.
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