Learn how to write a nursing care plan (NCP) in this step-by-step guide and in this comprehensive list of databases. We have more than 1000 samples of care plans. The nursing process works as a systematic guide for client-centered care with 5 sequential steps. These are evaluation, diagnosis, planning, implementation and Evaluation.
Nursing integrates the art and science of care and focuses on the protection, promotion and optimization of health and human functioning; the prevention of diseases and injuries; the facilitation of healing; and the alleviation of suffering through a compassionate presence. Nursing is the diagnosis and treatment of human responses and the promotion of care for individuals, families, groups, communities and populations, in recognition of the connection of all humanity. A nursing diagnosis is a clinical judgment that describes real or potential health problems or opportunities to improve the health of a patient, family or community. Care plans are an opportunity for nurses to demonstrate that safe and ethical care was provided in accordance with professional regulations. In this step, the nurse and client begin to plan which of the identified problems require attention first.
If you work in rural or isolated areas of the country (or the world), you may find that what nurses do greatly mimics the usual tasks of some doctors. When drafting a nursing care plan, you must first determine what type of care plan you are interested in. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetically ordered list of nursing diagnoses that cover more than 400 disorders. For example, if a goal is for the patient to seek counseling to treat alcohol dependence during hospitalization, but the patient is currently detoxifying and has mental problems, this may not be a realistic goal.
Following an evidence-based practice, the nurse uses her knowledge, experience and critical thinking to decide which interventions are a priority. Now that you have information about the client's health, analyze, group and organize the data to formulate your nursing diagnosis, priorities and desired outcomes. Physical exams may involve taking the patient's blood pressure, listening to the heartbeat, checking their reflexes, and examining their eyes, ears, or nasal cavities. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is responsible.
This format includes columns on diagnosis, goals and outcomes, interventions and nursing evaluation. It offers guidelines to help nurses make standardized nursing diagnoses, ensuring clear and effective communication and quality patient care. After assigning priorities for their nursing diagnosis, the nurse and client set goals for each determined priority. As mentioned, bedside nurses don't need to address all eight axes as part of their diagnostic process.
Achieving achievable goals is possible, while realistic goals take into account the context and potential barriers to achieving goal.
