The nursing care plan is a tasking and client oriented pattern of care which assists the nurse to plan and care for patients in the ward taking cognizance of the roles of other allied health personnel. This article highlights exclusively the do’s and don’ts in writing a nursing care plan.
Definition of key terms: these terms are defined operationally
1) NURSING: this is defined as the art and science rendering of holistic care to prevent illness, achieve wellness and promote health.
2) CARE PLAN: This is a step by step method of carrying out and evaluating efficiency of rationalized nursing actions.
STEPS TO WRITING A NURSING CARE PLAN
i) Organization and prioritization
1) Evaluate the disease condition given to you, by symptoms given or theoretically expected.
2) Reflect on the anatomical damage done to the part of the body affected.
3) Determine the stage of the ailment.
4) Differentiate an emergency from a surgical case, terminal disease or medical case to determine your mode of care.
5) Diagnose the patient considering location of pathology, glaring symptoms in order of priority.
6) Do not give similar diagnoses to a particular patient e.g. anxiety and disturbed sleep pattern may have similar nursing interventions and rationales making your plan of care monotonous.
7) Link your diagnosis to related factors which describe the etiology and pathology of the ailment not disjointing your diagnosis.
8) Make presentable evidences (SYMPTOMS) that fit into the etiology of the diagnosis e.g.
CORRECT: FOR GASTRIC ULCER
a) Acute pain (epigastric) related to erosion of mucous membrane, tissue inflammation evidenced by patients verbalization of pain, guarding and facial grimacing.
b) Acute pain related to inflammatory process evidenced by patient verbalization.
Reason: Nurse b is wrong because she failed to let us know i) location of pain, ii) what was inflamed, iii) and most importantly what patient verbalized. This diagnosis is obviously memorized from nursing textbooks and not applicable to disease condition above.
a. Write tallying objectives.
b. Make your objectives achievable with reasonable time limits. e.g.
CORRECT: Patient will verbalize relief of pain within 10 to 20 mins of nursing intervention.
INCORRECT: Patient will feel less pain within 10 mins of nursing intervention.
Reason: nurse b is wrong because i)verbalization was included as an evidence and should reflect as the as main objective ii) she cannot measure the level of pain felt by the patient using any instrument except by verbal response iii)the time limit of nursing action is way too specific, it must be a proximal range.
iv) NURSING INTERVENTIONS
9) This is the bulwark of the nursing care plan; the interventions must be tailored to combat the diagnosed problem and must be prioritized to suit the patients’ most pressing needs.
10) Always access before intervening, no matter how glaring the symptoms may be.
11) Administer only prescribed drugs or fluid after every other intervention.
12) Recheck them for appropriate prioritization.
13) Make sure you have not less than 5 interventions per diagnosis.
14) Do not use interventions that are not related to the diagnosis.
17) This is the scientific explanation/reasons for nursing interventions carried out on patient.
18) Link the intervention to scientific principles and explains how these interventions combat the pathological damage
19) Make rationales very short and detailed.
20) Do not repeat rationales for different nursing interventions.
20) This is the assessment of the outcome of the interventions carried out on the patient by evidenced-based observations.
21) May be positive or negative.
22) Must conform to the time limit from the nursing objective.
By Cornerstone, Jeremiah Udeme, RN
Phone No: 07031035220
Ukwuije Gordian, C. (2010) Essential Questions And Answers In Nursing 2,(2 ed).millenuim press limited ,Enugu.
Hinkle,J.L., Cheever M.K.,(2014). Brunner and suddarths Textbook Of Medical Surgical Nursing. (13 ed.)China: Lippincott Williams Wilkins publisher.
Ofunami O., (2014). Explicit of medical surgical nursing plus related anatomy and physiology (1 ed.). Nigeria Ncrptz Innovations.
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