CARE PLANS

DEFINITION

• A nursing care plan outlines the nursing care to be provided to a patient.

• It is a set of actions the nurse will implement to resolve nursing problems identified by assessment.

• Care plans are formed using the nursing process.

CHARACTERISTICS

• It focuses on actions which are designed to solve or minimize the existing problem.

• It is a product of a deliberate systematic process.

• It relates to the future. • It is based upon identifiable health and

nursing problems. • Its focus is holistic.

COMPONENTS

• The nursing care plan may consist of a NANDA nursing diagnosis with related factors and subjective and objective data that support the diagnosis.

• Nursing outcomes (or goals) to be achieved including deadlines.

• Nursing interventions with specific actions

Step 1

• Collecting subjective data and objective data.

• Subjective:what the patient tells you, c/o, s/s

• Objective: information based on assessments; what you see, hear, smell etc.

Step 2

• Organize the data into a systematic pattern, such as Marjory Gordon's functional health patterns

• This step helps identify the areas in which the client needs nursing care.

Step 3

• Based on Gordon’s, then make a nursing diagnosis.

• Nursing diagnosis also includes the relating factors and the evidence that supports the diagnosis

Diagnosis Example

• Ineffective Airway Clearance r/t tracheobronchial infection (pneumonia),

Step 4

• State the expected outcomes, or goals

• A common method of formulating the expected outcomes is to reverse the nursing diagnosis, stating what evidence should be present in the absence of the problem.

• Must be measurable, specific date, or level achieved

Outcomes Example

• Effective airway clearance as evidenced by normal breath sounds; no crackles or wheezes; respiration rate 14-18/min; and no cough by 10/17/07.

Step 5

• Interventions must be specific,

• How often it is to be performed, so that any nurse or appropriate faculty can read and understand the care plan easily and follow the directions exactly.

Intervention Example

• Instruct and assist client to TCDB ( to assist in loosening and expectoration of mucous) every 2 hours

Step 6

• Evaluation is made on the goal date set.

• Goal met or not?

• Plan of care modified, discontinued, or continued.