CARE PLANS

1
CARE PLANS
2
What is a Care Plan?

• Essential part of healthcare
• Often regarded as a waste of time
• Without a care plan important patient care issues
  might be neglected.
• Road Map to guide all involved in the patients
  care.
• Must always be individualized for each patients
  needs.
• To be effective needs to involve all members of
  the healthcare team that are involved in the care
  of the patient.

3
ASSESSMENT

• The first step in care planning is accurate and
  comprehensive assessment. In the acute care
  setting, a thorough admission nursing assessment
  should be followed by regular reassessments as
  often as the patient's status demands.
• Involves data collection to identify the
  patients actual and potential health problems

4
ASSESSMENT

• Subjective vs. Objective Data
• Subjective data
• Perception or reality experienced by the patient
• May come indirectly from family member,
  caregivers, other healthcare providers
• If a patient is physically or mentally not
  capable of answering questions these people may
  be crucial to your assessment
• Objective data
• Comes from the physical assessment of the patient
  and/or chart
• Use physical findings to verify your subjective
  data
• For example
• Pt states I am having difficulty breathing
  (subjective)
• Diminished lung sounds (objective) supports this
  data from the patient

5
Diagnosis/Problem

• After the initial assessment is completed, a
  problem list (nursing diagnosis) should be
  generated.
• Categorize the data to reach a conclusion about
  what the patient needs.
• Need to be prioritize them.
• Actual then potential
• Parts of the Diagnosis
• Label Describes the actual or potential problem
  
• Usually written NANDA form
• Etiology related to factors
• Signs/Symptoms list those that support the
  Diagnosis
• As Evidenced by
• Types of nursing diagnoses
• Actual
• Potential or Risk for
• Wellness - used for patients that are already
  healthy but want to maintain or improve their
  wellness.
• For Example Health seeking behavior related to
  lack of knowledge of a regular exercise program.

6
Diagnosis/Problem

• Dos and Don'ts of Nursing Diagnosis

7
Planning

• When you have your nursing diagnosis/problem list
  completed, look at each diagnosis/problem and ask
  yourself
• Will this problem get better?
• If not
• Can we keep it from getting worse?
• If the problem is not likely to improve and
  deterioration is inevitable then you should ask
  yourself
• What can we do to provide optimal quality of
  life for this patient, comfort and dignity for
  this patient?

8
Goals/Desired Outcomes

• Need to be
• Realistic
• Specific
• Measurable
• Realistic
• Attainable
• Have a timeframe
• Outcome that you as a student can evaluate in the
  time that you spend with the patient.
• Example
• Do not write a goal that states Stage 4
  pressure ulcer will improved by next week.
• Instead Stage 4 pressure ulcer will improve to
  a full thickness and width/length will decrease
  to ___x____ in 90 days.

9
Implementation

• Nursing interventions may be
• Physicians orders
• Facility protocols or accepted standards of
  practice
• Facility policies
• Need to be prioritized Actual first the
  Potential
• Need to be selected so that you can achieve the
  desired outcome or nursing goal.
• Method of individualizing patient care.
• Rationale why are you doing the intervention.

10
Evaluation

• Whether goals or desired outcomes have been met.
• If goal was met
• Continue to monitor
• Ask if timeframe could have been shortened
• Do any interventions need to be continued or can
  they be d/cd
• If not you need to ask yourself these questions
• Nursing interventions appropriate
• Was client/family involved in goal planning
• Have all interventions been carried out
• Do I need to revise interventions?
• Was timeframe specific or too vague?
• Do I need a new nursing diagnosis?
• Rearrange priorities to meet the changes in your
  care.

11
Reassessment

• Reflects the changes that were made
• Basic physiological needs must be met first.
• If goals not met need to find out why
• Revise outcomes or interventions or may need to
  write new ones.

12
(No Transcript)
13
Nursing Care Plan Page 2.L LABORTORY TEST (Blood,
urine, cultures, etc.)
HIGHLIGHT ABNORMALS
Nursing Care Plan Page 2.L
LABORTORY TEST (Blood, urine, cultures, etc.)
14
Nursing Care Plan Page 2.r Radiology,
Cardiopulmonary, Nuclear Med.
Nursing Care Plan Page 2.r Radiology,
Cardiopulmonary, Nuclear Med.
15





Nursing Care Plan pg. 3 MEDICATIONS

16





Nursing Care Plan pg. 4 Pt sex M F Age
Medical Dxs___________________________ Priority
1 , 2, 3, 4
17
(No Transcript)