Whether you work in an emergency room, intensive care unit, surgical floor, maternity ward or long-term care facility, a career in nursing requires a thorough understanding of patient care. To ensure appropriate patient care, nurses are required to write a strategic plan for the delivery of nursing care. This patient care plan involves extensive patient assessment and appropriate nursing interventions.
Step 1
Review the patient's medical records to establish a thorough understanding of his current health status. While reviewing the records, pay close attention to his medical history, previous surgeries and illnesses, current illnesses and medical conditions, laboratory test results and medication administration records.
Step 2
Speak with the previous nurse for a quick overview of the patient's condition for the past 24 to 48 hours. After speaking with the nurse, review the nurse's notes included in the patient's medical charts. Carefully examine any patient notes left by a nurse, physician, surgeon, dietitian, physical therapist, social worker and any other specialist working with the patient.
Step 3
Perform a thorough assessment of the patient. The exact assessment procedure depends on your facility's rules and regulations. However, most patient assessments include a physical examination of the hair, eyes, ears, skin, nails and mucous membranes. You should also record current blood pressure, pulse rate, temperature, heart sounds and lung sounds.
Step 4
Interview the patient as you assess her physical condition. The interview not only assesses the patient's mental awareness but also allows you to obtain information about her religion, occupation, family, hobbies, mood and attitude. You might also ask about her eating, sleeping and elimination habits.
Step 5
Assign an appropriate nursing diagnosis based on the patient's health status and medical condition. According to the North American Nursing Diagnosis Association, a nursing diagnosis "is a clinical judgment about individual, family, or community experiences and responses to actual or potential health problems and life processes." This diagnosis helps you determine the appropriate plan of care. Read about the selected nursing diagnosis in an approved medical-surgical nursing text.
Step 6
Determine the outcomes you wish to obtain through your nursing interventions. For example, if your patient's nursing diagnosis is "Risk for Impaired Skin Integrity," an appropriate outcome would be to keep the skin free of redness and irritation with no skin breakdown. You will likely need to develop several nursing outcomes for your patient. Outcomes should be specific and measurable.
Step 7
Establish a specific plan for treating your patient to obtain the desired outcomes. At this point, your ultimate goal is to determine what you as the nurse can do for the patient. Using the same diagnosis, appropriate interventions might include inspecting the skin for color changes or skin breakdown every three to four hours, helping the patient turn or shift positions every two hours and keeping the patient's skin clean and dry at all times.
Step 8
Implement your plan. Although you should attempt to follow your nursing care plan, understand that nursing care is dynamic and always evolving. As such, you must allow your plan of care to change when appropriate.
Step 9
Document your actions in the patient's medical record. Documentation includes observations made before nursing treatment, exact care given to patient, the patient's response to the care and the overall results of your interventions. Most facilities require you to include the date, the time and your initials for each note made in the patient's chart.
Step 10
Evaluate your nursing care plan, and make changes as necessary. During this final stage of the nursing care plan process, carefully compare your desired outcomes with your actual outcomes. If necessary, devise new interventions for achieving your desired outcomes. The strategic plan for nursing care continues to evolve throughout the patient's treatment.
References
- "Nursing Care Planning Guides"; Susan Ulrich, BSN, MSN, et al.; 2005
- Bergen Community College: Nursing Care Plan Guide
- Schreiner University: Nursing Care Plans
- The Free Dictionary by Farlex: Nursing Assessment
- North American Nursing Diagnosis Association: Nursing Diagnosis Frequently Asked Questions
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