NURSING CARE PLAN
INTRODUCTION •
The nursing care plan is written guide that organizes information about a client’s care into a
meaningful whole .
• It includes the actions nurses must take to address the clients nursing diagnosis and meet
the stated goals.
DEFINITION
A plan ,based on nursing and assessment and a nursing diagnosis ,carried out by a nurse .
PURPOSE
• To provide direction for individualized care of the client
. • To provide for continuity of care
• To provide direction about what needs to be documented on the client ‘s progress notes
• To serve as a guide for assigning staff to to care for the client .
WRITING A NURSING CARE PLAN
• A nursing plan of care documents the problem solving process.
• A nursing care plan outlines the nursing care to be provided to an individual /family
/community it is a set of actions the nurse will implement to resolve /support nursing
diagnosis identified by nursing assessment.
• The plan is a critical element in focusing nursing activity
. • To serve as evaluation criteria and meet the standards of the joint commission
• for accreditation of health care organizations (1996).
TWO IMPORTANT CONCEPTS GUIDE A NURSING CARE PLAN
1. The plan of care is nursing centered
2. The plan of care is a step by step process
NURSE WORK
• What is a care plan.
• Why do nurse write care plans
• What are the different parts of a care plan
• What other paper work will I need to know
• How am I evaluated
NURSING CARE PLAN
• Provide a direction for individualized patient care
. • Provide continuity of care for the patient with all hospital departments.
• Provide documentation on patient and family needs.
• Provides acuity for staffing needs.
.A STEP BY STEP PROCESS IS EVIDENCE BY THE FOLLOWING
• Sufficient data are collected to substantiate nursing diagnosis .
• At least one goal must be stated for each nursing diagnosis .
• Outcome criteria must be specifically designed to meet the identified goal
. • Each intervention should be supported by scientific rationale .
• Evaluation must address whether each goal was completely met or ,partially met.
GUIDELINESS FOR WRITING NURSING CARE PLAN
1.Date and sign the plan .
2.use the category headings
3.Nursing Diagnosis
4. Goals /Outcome Criteria
5.Nursing Orders Criteria
6.Evalution and include a date for the evaluation of each goal .
7.Use standardized medical or medical symbols and key words rather then complete
sentences to communicate your ideas.
8. Refer to procedure books or other sources of information rather than including all the steps
on a written plan .
9.Tailor the plan to the unique characteristic of the client by ensuring that the client choices
,such as preferences about the time of care and the methods used are included .the reinforces
the clients individually and sense of control .
10. Ensure that the nursing plan incorporate the preventive and health maintenance aspects
as well as restorative .
11.Ensure that the plan contains orders for ongoing assessment of client .
12.Include collaborative and coordination activities in the plan.
13.include plans for the client discharge and home care needs.
TYPES OF NURSING CARE PLANS
• As you care for people in various health care facilities ,you will discover a variety of
nursing care plan formats .
• Student nursing care plan
• Teaching plan
• CASE MANAGEMENT CARE PLANS
• COMPUTERIZED NURSING CARE
CARE PLAN:
• Provides acuity for staffing needs
. • Provides reimbursement for insurance which was started by Medicare and Medicaid and
now used by all insurance companies. This is how hospitals and patients receive payment .
NURSING DIAGNOSIS:-
Related NANDA Nursing Diagnoses
• Ineffective Role Performance
• Body Image Disturbance
• Chronic low self‐esteem
• Self‐esteem disturbance
• Situational low self‐esteem
• Personal Identity disturbance
HOW TO WRITE A CARE PLAN:-
• Begin with a complete assessment of your patient. Get as much information as possible
from the chart, such as lab data, x-ray reports,physician history and physical examination.
DATA COLLECTION:-
Subjective- • This is what your patient tells you.
Objectives— • This is what you see.
• This helps you decide what is really wrong with your patient. You must listen to
know what they are not telling you.
NURSING DIAGNOSIS:-
• it is not a medical diagnosis
• A nursing diagnosis is the plan of care for your patient which all member of the staff will
follow as they care for the patients.
INTERVENTION:- •
What are you going to do to help your patient reach their goal. This is what you do daily for
your patient
. • If you give your paper to a peer would they be able to follow your intervention or plan of
care.
NURSING RATIONALE:-
• This is the scientific reason you did this for your patient. You must tell us (cite) where you
got your information. This could be your from your books or a reliable internet sources.
EVALUATION:-
• Did your patient reach their goal in the time frame that you allowed for them.
• Did your patient not reach their goal and do you need to extend the timeframe or is this an
unreachable goal and you need to start over.
NURSING PROCESS IMPLEMENTATION:-
DEFINITION
IMPLEMENTATION IS the fourth step of the nursing process, formally begins after the
nurse develops a plan of care. With a care plan based on clear and relevant nursing
diagnoses.
• Implementation is the fourth step of the nursing process in which nurses initiate
interventions that are designed to achieve the goals and expected outcomes of the patient’s
plan of care.
• A direct-care intervention is a treatment performed through interactions with a patient that
can include nurse-initiated, physician-initiated, and collaborative approaches.
• Always think first and determine if an intervention is correct and appropriate and if you
have the resources needed to implement it.
PURPOSE OF IMPLEMENTATION:
- • Standardization of the nomenclature(e.g.,labeling, describing) of nursing interventions;
standardizes the language nurses use to describe setsof actions in delivering patient care
. • Expanding nursing knowledge about connections among nursing diagnoses, treatments,
and outcomes; connections determined through the study of actual patient care using a
database that the classification generates.
• Developing nursing and health care information systems
• Teaching decision making to nursing students; defining and classifying nursing
interventions to teach beginning nurses how to determine a patient’s need for care and to
respond appropriately.
• Determining the cost of services provided by nurses.
• Planning for resources needed in all types of nursing practice settings.
• Language to communicate the unique functions of nursing.
• Link with the classification systems of other health care providers.
PROCESS OF IMPLEMENTATION:-
• Reassessing the Patient
• Reviewing and Revising the Existing Nursing Care Plan
• Organizing Resources and Care Delivery
• Anticipating and Preventing Complications
• Identifing Areas of Assistance.
• Implementation skills
TYPES OF IMPLEMENTATION CARE:-
1.Direct care
• Activities of Daily Living
• Instrumental Activities of Daily Living
• Physical Care Techniques
• Lifesaving Measures
• Counseling
• Teaching
• Controlling for Adverse Reaction
• Preventive Measures
2.Indirect care
• Communicating Nursing Interventions
•Delegating, Supervising, and Evaluating the Work of Other Staff members
ARCHIVEING PATIENTS GOAL:
- ✓ Regardless of the type of interventions, you implement nursing care to achieve patient
goals and outcomes. In most clinical situations multiple interventions are necessary to
achieve select outcomes.
Another way to achieve patient goals is to help them adhere to their treatment plan
PROCESS OF IMPLEMENTATION:-
✓ Reassessing the client
✓ Reviewing the revising care plan
✓ Organising the resources
✓ Preventing Complications
✓ Implementing nursing intervention
✓ Documentations
SKILLS OF IMPLEMENTATION:-
✓ Cognitive skills
• APPLICATION OF CRITICAL THINKING
• RATIONALE FOR THERAPEUTIC INTERVENTION
• USE OF EVIDENCE BASED PRACTICE
✓ Interpersonal skills
• DEVLOP TRUSTING RELATION
• USE OF IPR SKILL
• COMMUNICATING PATIENTS PROBLEM
EVALUATION:-
INTRODUCTION
• The last phase of the nursing process, follows implementation of the plan of care,
• It’s the judgment of the effectiveness of nursing care to meet client goals based on the
client’s behavioral responses.
Definition
• Evaluating is a planned, ongoing, purposeful activity in which clients and health care
professionals determine the client’s progress toward achievement of goals/outcomes and the
effectiveness of the nursing care plan.
Elements of evaluation :-
1. Evaluation is continuous
2. Done immediately after implementation to make on the spot modifications in an
intervention.
3. Evaluation performed at specified intervals.
4.Evaluation continues until the client achieves the health goals or discharged from nursing
care.
5.Evaluation includes goal achievement & self care abilities.
6.Through Evaluation Nurses demonstrates responsibility accountability for their actions,
indicate interest in the results of the nursing activities.
PROCESS OF EVALUATING CLIENT RESPONSE:-
1. Collecting data related to the desired outcomes
2. Comparing the data with outcomes
3. Relating nursing activities to outcomes
4. Drawing conclusions about problem status
5. Continuing, modifying, or terminating the nursing care plan.
When determining whether a goal has beenachieved, the nurse can draw one of the
threepossible conclusions:–
1.The goal was met, that is the client response isthe same as the desired outcomes.
2.–The goal was partially met, that is either a shortterm goal was achieved but the long term
was not,or the desired outcome was only partiallyattained.
3.–The goal was not met.
Relationship of Evaluation to Nursing Process
✓ When goals have been partially met or when goals have not been met, two conclusions
may be drawn
✓ The care plan may need to be revised, since the problem is only partially resolved
✓ The care plan does not need revision, because the client merely needs more time to
achieve the previously established goals. So the nurse must reassess why the goals are not
being partially achieved.
