Nursing Care Plans

Nursing care plans play a vital role in everyday medical care, helping to ensure that the individual needs of each patient are met consistently. Medical care requires the cooperation of a variety of professionals and paraprofessionals, each of them needing an accurate assessment of the patient to perform their function effectively. Comprehensive care planning is essential to the process, keeping the myriad of important details about the care of each patient organized and accessible to the health care team.

To meet the needs of a patient, a complete clinical overview of the health status and history is necessary. This process of assessment and documentation of overall patient condition is generally the first step in any nursing care plan. A proper assessment should include both objective and subjective data. Objective data includes a physical examination, documenting vital signs, direct observation, and chart information like lab tests and their results. Subjective data records details such as patient complaints, prognosis and disease process, health care needs, and patient abilities or disabilities.

The next step in a comprehensive nursing care plan generally deals with the nursing diagnosis, documenting the health issues of a patient according to priority. Major issues, requiring the most intensive nursing care, are listed first, with all others listed in descending order of severity and concern. Input from the patient or family is important to this section of the nursing care plan.

Treatment and recovery goals are the next item to be addressed in most nursing care plans. This section details the method of treatment or care to be used for each health care issue that needs attention, the outcome that is anticipated, and the time frame in which these goals are expected to be met. Both short and long term plans ought to be included.

The development of an accurate and comprehensive nursing care plan is a process that is often underestimated, seen as just more paperwork, wasting time that could be better spent on direct patient care. However, the details included in the nursing care plan are crucial to ensure that vital patient information is available to all members of the health care team, helping to maintain smooth and coordinated care for the best possible outcome.

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