Guide for Nursing Care Plans
Understanding Nursing Care Plans
Nursing care plans act as a blueprint for patient care, ensuring safe and consistent nursing practice. They also serve as a communication tool for clinicians regarding patient care objectives. These plans are employed across hospitals, clinics, and various healthcare settings.
Different sectors apply specific nursing care plans to focus on areas like early mobility, skin integrity, and infection prevention. Nurses may also develop plans for specific body systems, such as the cardiovascular or respiratory systems. Most hospitals incorporate these plans into electronic health records (EHRs).
The Joint Commission describes a care plan as a framework facilitating communication and ensuring effective care. The American Association of Colleges of Nursing (AACN) emphasizes the need for suitable technologies and holistic planning in care delivery. For more on care plan guidelines, visit The Joint Commission and AACN.
Developing a Care Plan
With an understanding of their importance, let’s delve into creating nursing care plans. These plans center on what nurses can do for patients, showcasing nursing expertise.
Patient Evaluation
To create a tailored care plan, understanding the patient’s medical history is crucial. After a report from the previous caregiver, conduct a comprehensive assessment, including checking heart and lung sounds and evaluating wounds. Examine documentation on outputs like urine and wound drainage. If the patient is conscious, assess their pain, diet, and mobility. Conversations can enhance your understanding of their needs.
For example, post-surgical patients should be encouraged to move early to avoid complications. Explaining the benefits can motivate them and aid in goal setting.
Identify Issues
Recognizing patient issues involves assessing actual or potential health risks. A patient might be at risk of falls due to limited mobility or medication use. Nurses can incorporate fall prevention into the care plan based on assessments.
Once issues are identified, steps can be taken to reduce risks. Multiple clinical concerns might be included in the care plan.
Expected Outcomes
After identifying issues, define expected outcomes related to specific patient risks, ensuring they are achievable and measurable. For instance, a diagnosis of activity intolerance might aim for the patient to report no breathing difficulties and stable vital signs.
Reviewing Plans
Regularly review existing care plans for relevance. At the shift’s end, evaluate the plan’s effectiveness and address any obstacles. Some plans, like those for ventilated patients, may remain until conditions change.
Resources for Nurses
Many resources are available for care plans. Nursing school instructors might suggest specific texts. Specialized care plan books exist for fields like psychiatry or diabetes management.
If plans are electronic, review standard ones for your area. The North American Nursing Diagnosis Association (NANDA) provides valuable insights and resources like NANDA books. You can find further information and resources at NANDA International.
Future Directions
Care plans are vital for communicating patient needs and goals. While not the only basis for care, they highlight current patient challenges and goals. Crafting effective plans requires practice and experience.
Recognize that patients may have evolving care plans. Greater understanding enhances the quality of care, benefiting patients.
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