Nursing Care Plans

NURSING CARE PLANS

Regarded as a waste of time for most nurses but without a specific ‘document‘” a delineating the “Plan of Care“, important issues are likely to be neglected.  Care planning provides a guide for all who are involved with a patient/resident's care.  It is a comprehensive and intensive look at the patient/resident's status, active and possible problems to reach an expected goal.
It involves an interdisciplinary team approach by the Primary Physician, Nursing, Physical therapy, Occupational Therapy, Dietitian, Therapeutic Activity and other discipline as needed.  It should be written as simple as possible to alleviate any misunderstanding and being aware of the educational level of each discipline involved.

The Nursing Care plans:

• Problem
• Nursing Diagnosis
• Desired Outcome
• Interventions
• Evaluation

Problem:
 Inaccurate interpretation of stimuli, internal and/or.  As evidence by inability to remember items for 3 minutes, unable to follow simple direction to fold paper and put on lap, unable to state where he/she is.

Nursing Diagnosis: 
Alteration in Thought Process Associated with aging

Desired Outcome:
 Will be able to dress self with step-by-step direction without becoming frustrated.

Interventions: Designate what department/personnel responsible
    Assess for etiological and contributing factors (MD, Nursing)
    Assess history of confusion (onset/duration).  (MD, Nursing, Social Service)
    Set up routine times for care, meals and bathing. (Nursing)
    Assign primary care giver on all shifts. (Nursing)
    Approach in a calm manner and voice. (All)
    Evaluate medications for interactions. (MD, Nursing, Pharmacist)

Evaluation: Evaluation should be as needed but regularly every 3 months.

Remember the ultimate goal is to improve, prevent and promote Quality of life. 

Nursing Care Plan Constructor