Nursing Care Plans

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Nursing Overseas
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Nursing care plans play a vital role in everyday medical care, helping to ensure that the individual needs
of each patient are met consistently. Medical care requires the cooperation of a variety of professionals
and paraprofessionals, each of them needing an accurate assessment of the patient to perform their
function effectively. Comprehensive care planning is essential to the process, keeping the myriad of
important details about the care of each patient organized and accessible to the health care team.

To meet the needs of a patient, a complete clinical overview of the health status and history is
necessary. This process of assessment and documentation of overall patient condition is generally the
first step in any nursing care plan. A proper assessment should include both objective and subjective
data. Objective data includes a physical examination, documenting vital signs, direct observation, and
chart information like lab tests and their results. Subjective data records details such as patient
complaints, prognosis and disease process, health care needs, and patient abilities or disabilities.

The next step in a comprehensive nursing care plan generally deals with the nursing diagnosis,
documenting the health issues of a patient according to priority. Major issues, requiring the most
intensive nursing care, are listed first, with all others listed in descending order of severity and concern.
Input from the patient or family is important to this section of the nursing care plan.

Treatment and recovery goals are the next item to be addressed in most nursing care plans. This section
details the method of treatment or care to be used for each health care issue that needs attention, the
outcome that is anticipated, and the time frame in which these goals are expected to be met. Both short
and long term plans ought to be included.

The development of an accurate and comprehensive nursing care plan is a process that is often
underestimated, seen as just more paperwork, wasting time that could be better spent on direct patient
care. However, the details included in the nursing care plan are crucial to ensure that vital patient
information is available to all members of the health care team, helping to maintain smooth and
coordinated care for the best possible outcome.

Reference: http://www.med-help.net/nurse/nursing-care-plans.html