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Nursing Care Plan

Nursing Care Plan

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Published by: yumiko on Aug 29, 2009
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06/14/2013

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Nursing care plan
A nursing care plan outlines thenursing careto be provided to apatient. It is a set of actions the nurse will implement to resolvenursing problems identified byassessment. The creation of the planis an intermediate stage of thenursing process. It guides in theongoing provision of nursing care and assists in the evaluation of that care.
Characteristics of the nursing care plan
1.It focuses on actions which are designed to solve or minimize theexisting problem.2.It is a product of a deliberate systematic process.3.It relates to the future.4.It is based upon identifiable health and nursing problems.5.Its focus is holistic.
6.
It focuses to meet all the needs of the service user
.
Elements of the plan
In the USA, the nursing care plan may consist of aNANDA nursing diagnosiswith related factors and subjective and objective datathat support the diagnosis, nursing outcome classifications withspecified outcomes (or goals) to be achieved including deadlines,and nursing intervention classifications with specified interventions.
The nursing process
Care plans are formed using thenursing process. First the nursecollectssubjective dataandobjective data, then organizes the data into a systematic pattern, such as Marjory Gordon'sGordon'sfunctional health patterns. This step helps identify the areas inwhich the client needs nursing care. Based on this, the nurse makesanursing diagnosis. As mentioned above, the full nursing diagnosisalso includes the relating factors and the evidence that supports thediagnosis. For example, a nurse may give the following diagnosis toa patient with pneumonia that has difficulty breathing: IneffectiveAirway Clearance related to tracheobronchial infection (pneumonia)and excess thick secretions as evidenced by abnormal breathsounds; crackles, wheezes; change in rate and depth of respiration;and effective cough with sputum.(This Nursing Diagnosis is takenfrom the list of NANDA's functional health patterns,Disturbedpattern is "Activity and Exercise pattern")
 
After determining the nursing diagnosis, using the PES (Problem,Etiology, Signs and Symptoms) system, the nurse must state theexpected outcomes, or goals. A common method of formulating theexpected outcomes is to reverse the nursing diagnosis, stating whatevidence should be present in the absence of the problem. Theexpected outcomes must also contain a goal date. Following theexample above, the expected outcome would be: Effective airwayclearance as evidenced by normal breath sounds; no crackles orwheezes; respiration rate 14-18/min; and no cough by 01/01/01.After the goal is set, thenursing interventionsmust be established.This is the plan of nursing care to be followed to assist the client inrecovery. The interventions must be specific, noting how often it isto be performed, so that any nurse or appropriate faculty can readand understand the care plan easily and follow the directionsexactly. An example for the patient above would be: Instruct andassist client to TCDB (turn, cough, deep breathe) to assist inloosening and expectoration of mucous every 2 hours.The evaluation is made on the goal date set. It is stated whether ornot the client has met the goal, the evidence of whether or not thegoal was met, and if the care plan is to be continued, discontinuedor modified. If the care plan is problem-based and the client hasrecovered, the plan would be discontinued. If the client has notrecovered, or if the care plan was written for a chronic illness orongoing problem, it may be continued. If certain interventions arenot helping or other interventions are to be added, the care plan ismodified and continued.Since its inception, the nursing process has been developed andhoned by different authors. Additional detail has been added foreach stage of the process, and new or adapted stages have alsobeen suggested. The most recent 'repackaging' of the nursingprocess comes in the form of the ASPIRE approach to planning anddelivering care
. This approach - developed within Hull University(UK) as a teaching and learning tool - takes the 5-stage approachoutlined above and enhances it. 'Diagnosis' is retitled 'SystematicNursing Diagnosis' to reflect the process of diagnosis in addition tothe final product. An additional stage - 'Recheck' - is placed betweenImplementation and Evaluation, and reflects the information-gathering activities carried out by nurses, necessary to make aninformed judgement about the effectiveness of patient care.There are also care plans written for "at risk" problems, as well as"wellness" care plans. These follow a similar format, only designedto prevent problems from happening and continue or promotehealthy behavior.
 
Assessment
is the first stage of thenursing processin which thenurseshould carry out a complete andholisticnursing assessment of every patient's needs,regardless of the reason for the encounter. Usually, an assessmentframework, based on anursing modelis used.The purpose of this stage is to identify the patient's nursingproblems.These problems are expressed as either actual or potential. For example, apatient who has been rendered immobile by a road traffic accident may beassessed as having the "potential for impaired skin integrity related toimmobility".
A
nursing diagnosis
is a standardized statement about the health of a client (who can be anindividual, a family, or a community) for the purpose of providing nursingcare. Nursing diagnoses are developed based on data obtained during thenursing assessment.
Process of diagnoses
1.
Collect data
-
statistical data relevant to achieving a diagnosis.
2.
Cues/patterns
-
changes in physical status. (for example: lowerurinary output)
3.
Hypothesis
-
possible alternatives that could have causedprevious cues/patterns.
4.
Validation
-
taking necessary steps to rule out otherhypothesis, to single out one problem.
5.
Diagnosis
 
-
making a decision on the problem based onvalidation.
6.
Strategies
 
- taking necessary action to solve the problemand/or to provide adequate nursing care.
 
Nursing Diagnosis
:
Deficient Fluid VolumeHypovolemia; DehydrationNOC Outcomes (Nursing Outcomes Classification)Suggested NOC Labels

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