Nursing Care plan is a written guideline or blueprint for action of strategies to be implemented to help client achieve optimal health. Also is a set of standardized tools that are utilized to set priority in nursing action which support what nursing profession is intended to be “Care,Cure and Sacrifice”.

Nursing Care Plan is a nursing tool which allows the use of critical thinking that entails knowledge, experience and common sense that will transit in appropriate assessment and solving a short-term or long-term needs to provide holistic care which concerns every aspect of promotion of health, prevention of illness, alleviation of suffering, facilitate coping with dying patient.

 

Albeit, there’s no new technology that will take off the nursing care plan away from the nurses’ duty, hence you should not do away with nursing care plan as a Registered Nurse or Nursing Student.

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Is it important? YES, it is very important to all nurses. It serves as a legal document, also used in client evaluation in terms of quality assurance, helps to promote continuity of care, It guides the nurse over a specific outcome if achievable. Notwithstanding, Nursing Care Plan has no known misconception, it just depends on how you were being taught during the Basic Nursing School. This emerges with a vast knowledge on how to formulate a care plan for your patient. Nursing Care plan emanated from Fourth step in the nursing process.

NCP has 8 columns to be completed by the students and for the Registered Nurse practicing this scope is defined by there employer’s policy.

As a matter of fact I wish to further discuss the details of NCP for Nursing Students:

“STD – NONSE”

In the Column there must be:

  • S – S/N, T – Time, D – Date,
  • N – Nursing Diagnosis,
  • O – Outcome Identification,
  • N – Nursing Intervention,
  • S – Scientific Rationale,
  • E – Evaluation.

For the staff nurse, it may not  include scientific rationale based on hospital mode of operation. It is of the essence that before graduating as a registered nurse you are equipped with this tool.

How can you write a nursing care plan?

The best way to get it done and understand is just for you to comport yourself don’t panic, reassure yourself that you can do it then follow this step;
Step 1: Assessment
Step 2: Data Analysis and Organization
Step 3: Formulation of Nursing Diagnoses
Step 4: Settings Priorities
Step 5: Establishing Client Goals and Desired Outcomes
Step 6: Selecting Nursing Intervention
Step 7: Providing Rationale

Step 8: Evaluation

Step 9: Putting it on paper

Formulation of Nursing Care Plan

Example:

Medical Diagnosis: Bronchial Asthma

Nursing Diagnosis:
It is a clinical Judgement that provides selection of Nursing interventions according to NANDA list (North American Nursing Diagnosis Association) it helps to establish diagnostic label from its classification system.

  • Actual Nursing Diagnosis,
  • Possible Nursing Diagnosis,
  • Wellness Nursing Diagnoses,
  • Syndrome Nursing Diagnosis.

Components of Nursing Diagnosis are;

  • Problem
  • Etiology
  • Symptom.

Problem is strict nursing diagnosis which is INEFFECTIVE BREATHING PATTERN.

Etiology is a related factor could be INHALATION OF IRRITATING SUBSTANCE
Symptom is evidence like WHEEZLING RESPIRATION.

Outcome Identification:
This is an establish priorities; client focused goals and outcome identification. It must be specific, measurable, attainable, realistic and time-framed.

Example; PATIENT WILL BE ABLE TO BREATH WITH EASE WITH SPO2 OF 96% WITHIN 45MINUTE OF NURSING INTERVENTION.

Nursing Intervention:
A nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.

Examples; ASSESS PATIENT VITAL SIGNS ESPECIALLY RESPIRATION. 

Scientific Rationale:
This is the reason behind the nursing action which must be justified.

Example; TO SERVE AS A BASELINE DATA.

Evaluation:
The judgement of the effectiveness of nursing care to meet its goals based on the patients behavioral responses

Example; PATIENT BREATH WITH EASE WITH SPO2 OF 96% WITHIN 45MINUTE OF NURSING INTERVENTION

Written By Daniel OYE

Interning with FNA

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