Providing adequate care for patients is the duty of the health care staff that takes care of the patient. The registered nurse is a part of the medical facilities and she makes a care plan to chalk out how she will care for the patients.
Nursing care plans are vital for providing care to patients in various settings and even the length of time varies, depending on the patient’s health condition, prognosis and diagnosis.
The different components make up a common nursing plan. It is important to formulate an effective, well-thought-out plan so as to provide better patient-oriented care.
1. Assess your Patient
It is important that you get the details of the patient’s health either directly from the patient or people concerned with the patient like relatives or doctors. Collect information about the patient’s health history, family history etc.
the nurse should find out the type of diseases that run in the family. It is important to ask the patient about the living situation. The home he stays in, people living with him while he is sick should be noted down.
A physical examination should be conducted. A nursing plan should also include how to address the care for the patient based on the patient’s current and potential problems.
2. Identify Problems
The information gathered about the patient should be studied properly. All the physical assessment and medical records needs a good checking.
Look for information that has impaired body functions or even emotional disturbances. The nurse has to write down the potential problems that your client goes through and also the issue that is causing or aggravating the problem.
The basic elements of the nursing plan also include risk factors, interventions, rationales and outcomes based on the diagnosis of the patient. Nursing outcomes also include pain control and coping measures.
3. Write Down Nursing Diagnoses
The NANDA-I consists of a list of international nursing diagnoses that every registered nurse must have and use to write their nursing diagnoses.
One has to select the nursing diagnoses that describe the problems in the best possible way that you identified. The nursing diagnoses should be noted down and then attached them with the statement “related to”.
The nurse has to write down goals for your client that is based on diagnoses that the nurse has noted down.
The goals should be realistic and must focus on solving the patient’s problems through nursing interventions. They should be measurable so as to see if the goals have been reached or not.
5. Nursing Interventions
The nurse must write down possible interventions that are performed to achieve the nursing care plan goals. A patient with chronic pain should be aimed at reducing pain and increasing the comfort levels in the patient.
Interventions may include, pain management, complementary pain relief therapies, education regarding managing medications or alternative pain relief like acupuncture, massage, acupressure or heat therapy.
6. Evaluate the Patient
The nurse must evaluate the condition of the patient on a regular basis. If the patient is on a care plan, special attention is needed and pays special attention to details.
For instance, the patient with chronic pain should be checked for the location of the pain, the duration, the severity of pain that should be rated on a scale of 1 to 10 and such other factors.
The information thus gathered would help to focus specifically on the particular illness and would be a lot of help in determining the best methods for tackling the problem in the patient and increasing the comfort levels.
Help the patient develop a management strategy that deals with chronic pain through education and helping with answering his question including offering continuity of care.
The patient’s progress should be noted throughout the treatment on a continuous basis, so that goal are identified and measurable.
If the patient has reached the goals that have been set in the nurse care plans, then your care plan has been successful.
If however, some of the goals are not met then it is important to assess the patient again. Write down evaluation statements noting down the goals the patient has reached or not.
The nursing care plan is shared with the nursing team and the shift change also reports changes in the patient. The shift nurse also updates the patient’s chances.
The members of the nursing team have their input into the care plan. Members of the nursing team have different perspectives of the patient and the patient’s progress.