A proper care plan ensures speedy recovery.
People involved in health care, including doctors and nurses, often require a road map which guides them through the patient's journey of recovery. A patient plan of care is one such document which assures that no aspect of the patient's health is neglected. It is also used by the patient to understand the detailed diagnoses, the adopted course of medication and the changes taking place in his body.
Instructions
1. Figure out the eventual or long-term aim of medication by considering the individual patient's, family's or community's response towards that particular health issue and formulate a statement which specifies that aim. If, for example, a patient comes in with the problem of chest burns arising due to a high blood pressure problem, the statement could be: "Patient should have a healthy blood pressure with no chest pains by the time he is discharged."
2. Take a thorough and complete assessment of the patient to figure out the extensive nature of the problems she or he face. Choose a nursing diagnosis out of the options provided in the approved list of nursing diagnoses by NANDA. Note that it is important to include what disease or pain is the diagnosis possibly "related to" and what subjective and objective signs or symptoms provide "evidence" to the diagnosis of the undertaken assessment.
3. Discover the client outcomes which respond to the interventions taken upon by the nurses. These nursing outcomes classification (NOC) would be on the basis of the NANDA diagnosis conducted previously. The outcomes should necessarily be goals which can be met with patient care in the short-run.
4. Choose the recommended actions that the nurse must undertake in order to help the client recover from the problems identified in Step 3. Nursing Interventions Classifications (NIC) would be based upon factors that relate to or caused the disease and these interventions should reflect the actions the nurse would take to "intervene" into the patient's problem(s). Note that the statements defining these should ideally be to-the-point, brief, clear and purposeful.
5. Mention and elaborate the reason behind all suggested and undertaken nursing interventions. Feel free to use other sources but do cite them properly, and accurately refer the number of pages used.
6. Analyze the patient's progress closely and see to what extent does it meet the NOC's outlined in step 3. Asking the following questions or statements helps in evaluation:
Did the medication meet the outcome completely? Or just partially? Or not met?
If not met, then why?
Would the outcome be carried on, modified or terminated? If so, then why?
Note that NANDA termination would lead to the termination of NOC and NIC too.
Tags: Note that, blood pressure