How to Write a Nursing Care Plan
To create a plan of care, nurses should follow the nursing process:
- Assess the patient.
The nurse starts by reviewing all relevant data, including (but certainly not limited to): medical history, lab results, vital signs, head-to-toe assessment data, conversations with the patient and their loved ones, observations from other care team members, and demographic information. The nurse uses this data to assess the patients:
• Physical, emotional, psychosocial, and spiritual needs
• Areas for improvement
• Risk factors
- Identify and list nursing diagnoses.
After a thorough assessment, the nurse identifies nursing diagnoses — health problems (or potential health problems) that nurses can handle without physician intervention. For example, acute pain, fever, insomnia, and risk for falls are all nursing diagnoses. The North American Nursing Diagnosis Association (NANDA) curates an official nursing diagnosis list, which includes definitions, features, and commonly applied interventions for each diagnosis.
- Set goals for (and ideally with) the patient.
What are the desired outcomes, and how will the patient get there? The nurse answers these questions based on the assessment, nursing diagnosis, and feedback from the patient. Together, the nurse and patient set reasonable goals that can be achieved with nursing interventions and (in some cases) effort by the patient. Goals can be short-term (e.g., resolve acute pain after surgery) or long-term (e.g., lower the patient’s A1C with better diabetes management). Then the nurse prioritizes goals based on urgency, importance, and patient feedback. Nurses can also use Maslow’s hierarchy of needs to help prioritize patient goals.
- Implement nursing interventions.
Nursing interventions are actions taken by the nurse to achieve patient goals and get desired outcomes — for example, giving medications, educating the patient, checking vital signs every couple hours, initiating fall precautions, or assessing the patient’s pain levels at certain intervals. This is also where the nurse documents care as they perform interventions, including dependent nursing interventions ordered by physicians.
- Evaluate progress and change the care plan as needed.
Finally, the nurse monitors and evaluates the patient and the nursing care plan on a regular basis to answer the question: Are the nursing interventions helping the patient reach their goals and desired outcomes, and should those interventions be changed, terminated, or continued?
How to Implement Nursing Care Plans in Your Hospital
For care plans to be useful, they need to promote effective communication in nursing. They need to be shareable, easy to access, and always up to date. That means they need to be electronic, and preferably integrated into the EHR for cloud access and real-time inter-professional collaboration.
Leading EHR providers have care plan functionality built into their systems, with lists of nursing diagnoses and interventions. Finding these resources is not always intuitive, but with a little help from IT, you can build custom care plan forms that are part of each patient’s record and each nurse’s workflow. With the right integrations, you can even automate parts of the care plan so certain fields get automatically populated with information. That means fewer fields for nurses to fill out and regularly update.
Nurses are also more likely to comply with care plan requirements if they don’t have to track down an available computer first. If they can access the care plan from secure mobile devices, they can review and update care plans at the patient bedside, refer to them regularly to help guide patient care, and even use them as a patient education tool.
Smartphone-wielding nurses can do more than manage care plans on the go. They can also use HIPAA-compliant clinical workflow solutions that let them securely talk, text, or have a group conference about the plan of care.
Supported by technology and a secure communication platform, a patient care plan becomes a resource for nurses to get all the information they need in one place, a roadmap for recovery, and a collaboration tool that helps ensure continuity of care.
Write a care plan for your patients using the example above who is also on hospice recently by let the family member to how he/ she will be taking care of before he/she dies.
Hx of rectal prolapse
Frontal sinus hypoplasia
S/P left cataract surgery
Hx of Macrocytosis
Broken hips (the right hip) this happen recently .
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