A systematic phase of nursing process that involves decision making and problem solving.In planning the nurse refers to the client assessment data and diagnostic statements for directions in formulating clients goals and designing interventions.
Any treatment based upon clinical judgment and knowledge that the nurse perform to enhance patient outcomes.
Types of planning
Initial planning:Performed by initial nurse that does admission.
Ongoing planning:Done by all nurses that work with the patient.Nurses obtain new information and and evaluate clients response to care.They can individualize the plan of care further.Ongoing planning also occurs at the beginning of the nurse shift.The nurse determines any change in the client health status,set priorities for the client,problems to focus, and coordinates nursing activities.
Discharge planning:Anticipates and planning the needs after discharge.
Informal nursing care plan
Strategy for action that exist in the nurse mind.
Formal nursing care
Written or computerized guide that organizes information about the client care.Provides continuity of care.
Standardized care plan
Formal plan that specifies the nursing care for groups of clients with common needs.Ex clients with MI.
Individualized care plan
Plan tailored to meet unique needs of specific clients.They are not addressed by standardized plans.
Complete plan of care
Includes several documents that describe the routine care needed to meet basic needs,address the clients nursing diagnoses and collaborative problems, and specify nursing responsibilities.
Pre-developed to indicate the actions commonly required for a particular groups of clients.May include both the primary care orders and nursing interventions.
Written documents about policies,rules,regulations or orders regarding client care.
Formats for nursing care plans
Organized in four sessions:problems or nursing diagnoses, goal/desired outcomes,nursing interventions and evaluations.
Student care plan
Long version for leaning purposes.
Computerized care plans
Create and store nursing care plan.Can generate both standardized and individualized care plans.
Multidisciplinary care plan
Is an standardized plan that outlines the care required by a clients with common,predictable usually medical conditions.Also referred as collaborative and critical pathways.Does not include detailed nursing activities.
Guidelines for writing nursing care plans
1.Date and sign
2.Use category heading
3.Use standardized/approved medical or english symbols and key words rather than complete sentence.
5.Refer to the procedure book or other sources of information rather than including all the steps on a written plan.
6.Tailor the plan to the unique characteristics of the client by ensure that the clients choices are included.
7.Ensure incorporation of preventive and health maintenance aspects as well as restorative ones.
8.Ensure ongoing assessment.
9.Include collaborative and coordination activities.
10.Include plans for the clients discharge and home care needs.
The planning process
2.Establishing client goals and desired outcomes
3.Selecting intervention and activities.
4.Writing individualized nursing intervention on care plans.
is the process of establishing a preferential sequence of addressing nursing diagnoses and interventions.
Nurses usually follow Maslow`s hierarchy of needs when setting priorities.Physiological needs such as air,food and water are basic to life.
Describe in terms of observable responses,what the nurse hopes to achieve by implementing nursing interventions.
Broad statement about client`s status
Specific observable criteria used to evaluate if the goals have been met.
Nursing Outcomes Classification(NOC)
A taxonomy describing client outcomes that respond to nursing interventions.
specific patient state that is the most sensitive to nursing interventions and for which measurement procedures can be defined.
Activities and actions that the nurse performs.Written and identified during the planning step but performed during the implementation step.
Those activities that nurses are license to initiate on the base of their knowledge and skill.
Activities carry out under the orders or supervision of a licensed physician.
Activities that the nurse carries out in collaboration with other health care team members.