Nursing Care Plan

Being a health care worker requires crucial information for the patient’s welfare. Nursing care refers to the ability to provide services involving planning, delegation, provision and supervision. Nursing care plans allows a proper discussion between the health care provider, patient, and other relevant subjects. Nursing Care Plan refers to a certain nursing process which specifies and identifies the needs of the patient and potential risk factors. This certain process enables nurses to effectively and consistency care for the patient.

 

Nursing care plans have specified objectives which are required to be achieved. the goals and objectives of writing a nursing care plan includes Promoting evidence-based nursing care and to render pleasant and familiar conditions in hospitals or health centers, Support holistic care which involves the whole person including physical, psychological, social and spiritual in relation to management and prevention of the disease, Establish programs such as care pathways and care bundles. Care pathways involve a team effort in order to come to a consensus with regards to standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease, Identify and distinguish goals and expected outcome and Review communication and documentation of the care plan as well as Measure nursing care.

The first stage in creating a nursing care plan is to use evaluation procedures and data collection tools to develop a client database (physical assessment, health history, interview, medical records review, diagnostic studies). A client database contains all of the information acquired about a person's health. To construct a nursing diagnosis, the nurse must first identify the linked or risk factors as well as the distinguishing characteristics. Some agencies or nursing schools have their own assessment formats that you might utilize to help you with your research.

 

Nursing diagnoses is the second phase in creating a nursing care plan NANDA nursing diagnoses is a consistent method of detecting, focusing on, and dealing with specific client needs and responding to real or potentially serious issues Known as nursing diagnoses, these are actual or future health concerns that can be avoided or remedied through autonomous nurse action.

The next phase is the Short Term and Long Term Goals. Measurable and client-centered goals and outcomes are required. Focusing on problem prevention, resolution, and rehabilitation is used to create objectives. Short-term and long-term objectives might be set. In an acute care situation, the majority of the nurse's time is devoted on the client's immediate requirements, hence most goals are short-term. When it comes to clients who have chronic health problems or reside at home, nursing homes, or extended-care facilities, long-term goals are frequently adopted. Short-term goal – a statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days. Long-term goal is a target to be fulfilled over a longer period, frequently over weeks or months. Discharge planning on the other hand has the purpose to promote continuing restorative care and problem resolution through home health, physical therapy, or other referral sources by naming long-term goals.

Nursing interventions on the other hand are activities or actions that a nurse takes to help a client reach their objectives. The interventions suggested should focus on eliminating or lowering the nursing diagnosis' cause. Interventions in risk nursing diagnoses should focus on minimizing the client's risk factors. This step occurs after the design and writing of nursing interventions during the planning stage of the nursing process; however, they are actually carried out during the implementation stage. Rationales explain why the NCP chose the nursing intervention. The last part is the evaluation. In this activity, the client's progress toward accomplishing goals or intended outcomes, as well as the effectiveness of the nursing care plan, are evaluated (NCP). An important part of the nursing process is evaluation, as the results of this stage decide whether the nursing intervention should be ended or prolonged, or adjusted.


Example:


ASSESSMENT

  • SUBJECTIVE DATA:

“I always seem to be anticipating disaster”,

“Sometimes, simply the thought of getting through the day makes me nervous”, “Sometimes I’m worried and I can’t identify the source” as the patient stated.

 

 

  • OBJECTIVE DATA:

“jumpiness,” an occasional “smothering sensation”

 

Vs/

BP-145/92

RR- 18

T- 98.4 F

P- 80

 DIAGNOSIS

  •                  PROBLEM IDENTIFIED:

                            ANXIETY


  •                 NURSING DIAGNOSTIC STATEMENT: (2 OR 3 PART)

                             anxiety related to perceived threat to biologic integrities evidence by                                     restlessness

  •                 CAUSE ANALYSIS (WITH REFERENCE):

                                Abnormalities in a brain neurotransmitter called gamma-aminobutyric acid —                                   which are often inherited — may make a person susceptible to GAD. Life events, both                            early life traumas and current life experiences, are probably necessary to trigger the                               episodes of anxiety.

https://www.health.harvard.edu/anxiety/generalized-anxiety-disorder


PLANNING

  • SHORT TERM OBJECTIVE (WITHIN THE SHIFT):

                 The patient will be able to Identify, verbalize, and demonstrate techniques to control anxiety

 

  • LONG TERM OBJECTIVES (UNTIL DISCHARGE)
                The client will be able to manage negative thoughts and worries, client is able to                                 acknowledge and be aware of the certain cause of her anxiety


INTERVENTIONS

  • INDEPENDENT:

  1. ·         Use empathy to encourage the client to interpret the anxiety symptoms as normal
  2. ·         Rule out withdrawal from smoking as the cause of anxiety
  3. ·         Encourage the client to use positive self-talk..
  4. ·         Provide clients with a means to listen to music of their choice or audiotapes.
  5. ·         . Assess for influence of anxiety on medical regimen.
  6. ·         Teach the client/family the symptoms of anxiety 

  • DEPENDENT/COLLABORATIVE:

 

  1. Use massage therapy to reduce anxiety.


  • RATIONALE

  1. ·         The way a nurse interacts with a client influences his/her quality of life. Providing psychological and social support can reduce the symptoms and problems associated with anxiety.
  2. ·         When withdrawing from either sedatives or alcohol, participants in this study demonstrated elevated levels of anxiety and nervousness
  3. ·         Reducing negative self-talk and increasing positive self-talk can be beneficial for all types of anxiety
  4. ·         Music can provide an effective method of reducing potentially harmful physiological responses arising from anxiety
  5. ·         Anxiety can affect a patient’s ability to complete their medical regimen as prescribed, including taking medications, exercise, diet, and follow up therapies
  6. ·         Teach families to have a general understanding of what is happening to the patient with anxiety and help them to accept assistance to overcome their anxiety
  7. Massage was shown to be an excellent method for reducing anxiety


EVALUATION

  • SHORT TERM OBJECTiVES:

         The client was able to Identify, verbalize, and demonstrate techniques to control anxiety.

  • LONG-TERM OBJECTIVES:

         The client is able to manage negative thoughts and worries, client is able to                       acknowledge and be aware of the certain cause of her anxiety


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