What does a Nursing Care Plan entail? Essay Paper

What does a Nursing Care Plan entail? Essay Paper

What does a Nursing Care Plan entail? Essay Paper

A nursing care plan refers to a formal process that identifies the existing patients’ needs or risks. What does a Nursing Care Plan entail? Essay PaperIt includes the patient’s condition, clinical diagnosis, and the teams’ goals developed for a particular patient as well as a measure of the patient’s progress. Nursing care plans provide for communication among the nurses resulting in the provision of consistent and high-quality care (reference). The objectives of writing nursing care plans include but are not limited to the promotion of evidence-based nursing, supporting holistic care, establishing pathways, reviewing of communication and care plan documentation, identification and distinction of goals and expected outcome, and measurement of nursing care.

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Elements of a Nursing Care Plan

  1. Patient Assessment

Patient assessment entails a comprehensive evaluation of both the subjective and the objective symptoms and vital signs that a patient presents with to the hospital. Nurses are responsible for taking and recording patient assessment data. The patient’s assessment relates to abilities and areas such as psychosocial, emotional, physical, cultural, cognitive, spiritual, functional, environmental, age-related, and economic(reference).

  1. Nursing Diagnoses

Creating a nursing diagnosis is the second element of the nursing care plan. Nursing diagnoses are developed based on the subject and objective data collected during the process of patient assessment. Nurses must follow the North American Nursing Diagnosis Association (NANDA) when making a diagnosis that must be based on a patient’s clinical manifestation, condition, and risks.

  1. Anticipated goals/outcomes

Anticipated outcomes/ goals highlight patients’ both short-term and long-term goals. Some of the short-term goals that patients might be seeking to achieve would include pain reduction and an improvement of vital signs such as blood pressure and body temperature. Long-term goals would include a patient recovering from an illness within a specified time frame. It is vital to note that the goals must be directly related to the nursing diagnosis to be achievable(reference).

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  1. Implementation

Implementation describes a process that describes in-depth how the nursing team can achieve the outlined goals. Specific nursing interventions are usually planned based on the set goals. The implementation section outlines the specific care which the nursing teams have offered to the patient. Some of the processes of care that could be described in this section include the administration of medication, surgical procedures performed, or other care-related activities that aim at managing a patient’s health condition(reference).

  1. Evaluation

Evaluation is the last part of the nursing care plan. This part usually describes how the patient has reacted and responded to the nursing interventions provided. This section also highlights how the goals were met or unmet. It is vital to note that if the set goals were not met, the plan is usually revised and if they are met, the nurse may opt to design more goals and interventions to help the patient achieve optimal health status.

  1. How Nursing Care Plans are Created

Nursing care plans are designed immediately after a patient is admitted to a health facility. The plan is continually updated to indicate the patient’s response to interventions applied as well as possible achievement of the set goals and expected outcomes.

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Types of Nursing Diagnoses according to NANDA

The four types of diagnoses according to NANDA are problem-focused, risk, health promotion, and syndrome.

  1. Problem-Focused Nursing Diagnosis

It is also known as actual diagnosis and focuses on a patient’s problem manifesting during the time of the assessment. This diagnosis is based on the signs and symptoms that a client exhibits during the assessment. This type of diagnosis consists of three elements namely: nursing diagnosis, related factors as well as defining characteristics. Examples of actual diagnosis include type 2 diabetes based on signs such as increased thirst, blurred vision, frequent urination, hunger, and fatigue among others(reference).

  1. Risk Nursing Diagnosis

Risk nursing diagnosis is one made based on the presence of risk factors that show that a problem is likely to develop unless medical practitioners intervene (reference). In this type of diagnosis, a medical problem does not necessarily exist. The diagnosis entails risk factors and risk diagnostic labels. Examples of risk nursing diagnosis would include risk for falls as indicated by muscle and joint weakness and risk for infection due to the prevalence of immunosuppression.

  • Health Promotion Diagnosis

The health promotion diagnosis commonly known as wellness diagnosis refers to a judgment based on a person’s motivation and desire to improve their well-being. Health promotion is directly concerned with a person’s readiness to make changes that are likely to result in better health outcomes. Health promotion is also concerned with an individual, community, or family transition from a specific level of wellness to a higher level of wellness. Examples include a person’s readiness to engage in physical activity to lose excess body fat or a person’s readiness for spiritual wellness.

  1. Syndrome Diagnosis

Syndrome diagnosis is the fourth type of diagnosis referring to a clinical judgment based on a cluster of problems or risks that are predicted due to a certain event (reference).  Examples of syndrome diagnoses include chronic pain syndrome and post-trauma syndrome.

Works Cited

The list of references follows

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