This week we are working on our first nursing care plan.

A nursing care plan consists of

Assessment

• subjective (what the patient says)
• objective – physical assessment of patient

Nursing Diagnosis

These provide a basis for selection of nursing interventions.  Example:

• “acute pain related to (r/t)  pressure on spinal nerves as evidenced by pt oral report of pain of 6 on a 0-10 scale”

• An actual nursing diagnosis– describes human responses to health conditions or life processes that exist in an individual or family
• A risk nursing diagnosis describes human responses to health conditions of life processes that will possibly develop in a vulnerable individual.
• A health promotion nursing diagnosis is a clinical judgement of a persons  motivation and desire to increase well being.  “readiness for enhansed conmfort
• A wellness nursing diagnosis – describes human responses to levels of wellness in and individual or family that have readiness for enhancement.

A nursing diagnosis has two parts:

• The diagnostic label – is the name of the nursing diagnosis approved by NANDA .  They include descriptors  used to give additional meaning to the diagnosis.  Ex:
• Diagnosis : impaired gas exchange  (characteristics Dypnea, abnormal rate, rhythm or depth of breathing, abnormal skin color, etc)
  
• Related factors – a condition of etiology identified from the clients assessment data.
• Diagnosis with related to- impaired gas exchange r/t ventilation/perfusion imbalance.

Planning

These are the treatment goals set by the nurse for client centered  care. A nurse sets client centered goals and expected outcomes and plans nursing interventions to get to those goals.  These are set in order of priority.

• example:  Pt will improve ventilation/ perfusion deficit.   Expected out come : pt will reach 12oo on incentive spirometer within 2 days.

Implementation

The step in the nursing process that begins after care planning.  Nursing interventions are initiated.  A nursing intervention is any treatment, based on clinical judgement based and knowledge that a nurse performs to enhance client outcomes.  These can be direct care or indirect care.

• Direct care interventions are treatments performed through interactions with the clients in the form of things such as  medication administration, insertion of  and intravenous infusion, or counseling in a time of grief.
• Indirect care – are interventions being performed away from the client but on behalf of the client. ex: managing the patient environment so it is safe.

Evaluation :

includes 5 elements

1. Identifying the evaluative criteria or standards.
2. Collecting data to deterimine whether the criteria or standards are met.
3. interpreting and summerizing findings
4. documenting findings and any clinical judgement
5. terminating, continuing or revising care plan.

I am still learning to put a care plan together and do not fully understand it yet.