Writing a nursing care plan is a skill that an aspiring nurse must acquire since it is an essential element of his or her work. It also helps in patient care because every individual is handled professionally by identifying the needs of the patient and the way to address those needs. In this article, the process of writing the nursing care plan will be described in great detail, as well as care plans for certain pathologies, and adding rationale to them will be discussed. It is imperative to take some time and learn how to prepare a basic nursing care plan before proceeding with its further elaboration.
Understanding the Basics of Writing a Nursing Care Plan
Nursing care plan is a multi-faceted written communication that contains information concerning a specific patient need and the particular action the nurse is going to take in response to the need. Sample nursing care plans will usually contain an overview of the assessment process of a particular patient. This includes collecting information based on the patient’s history, complaints, and clinical observations including; pulse, temperature, and blood pressure among others. This evaluation makes the nurse come up with a nursing diagnosis that outlines the patient’s actual or potential health issues.
The second aspect focuses on goals that have to be set down for the patient after the diagnosis has been made. Such goals should be clear, specific, measurable, and achievable and must touch on the feasibility of those goals within a given time frame. The plan then identifies the steps that are nursing interventions that will help in accomplishing the above goals. Such measures may involve the use of drugs, application of patient teaching for understanding, alteration of patients’ behavior, or any other related activity. Last, the nurse assesses the patient’s progress to the above and or proposed goals on the care plan; and modifies it accordingly.
How to Write a Care Plan Nursing
As it was observed, writing a plan of nursing care is an accurate process and requires a lot of planning. It includes a diagnosis that is not limited only by the somatic condition of the patient, but also by his or her psyche and psycho-emotional condition too. This approach aids in forming an overall perception of the patient’s condition to establish a nursing diagnosis that addresses the patient‘s requirements appropriately. The initial goal once the diagnosis is in place is set a specific and measurable goal by the nurse. For instance in hypertension, an objective may be to decrease the blood pressure to normal levels within a given time frame. The care plan thus lists the map goals and how these are to be attained through the interventions that may include administration of drugs, change in diet, regulation of blood pressure among others.
Assessment forms an important step within the care plans. Meaningful goals and objectives are further reviewed and monitored periodically by the overall management of the patient to know if there are any changes in the goals and objectives that need to be done in the course of management. This ongoing process helps to align the care plan to the current status, thus, making the care plan effective.
Documenting Care plans for particular diseases
It is important to understand that each patient has his or her unique needs about health, and therefore the specific nursing care plan for treatment shall always vary. For instance, when developing a nursing care plan for an asthma attack, the actions are on how to relieve the symptoms instead of a future attack. This might involve topping up the patient’s bronchodilator, teaching him or her what habits to avoid, and assessing respiratory status.
Consequently, a nursing care plan for bronchial asthma would include long-term goals such as adhering to inhaled corticosteroids and routine use of Peak flow measurement. It is also important to teach the patient regarding the correct use of inhalers and the importance of strictly following the doctor’s prescribed medications.
As for situational low self-esteem, the care plan may contain actions focused on the patient’s self-esteem increase. This could therefore involve availing counseling services and insisting that the patient engage in activities that enhance a feeling of self-achievement coupled with encouragement from the nursing staff.
In the case of hypertensive patients, the nursing care plan involves the prescription of medicine as well as diet and exercise as well as constant checks on blood pressure. The nurse might also offer the patient a lesson regarding accommodations they should make in terms of dieting, stress, and the need to follow the recommended treatment regimes.
How to Write Rationale in a Nursing Care Plan
Writers have varying methods of presenting a rationale for a nursing care plan. The following are some of the ways that writers use to write a rationale in a nursing care plan. The purpose of writing a rationale is essential for the contingency of the nursing care plan. The rationale gives the justification as to why a certain nursing intervention has to be undertaken thus making the course of action fully evidence-based. For example, if a nurse decides to give a certain medication, the rationale may contain how the given medication can help to solve the problem of a patient, and what results should be expected.
Recording rationales in the care plan does not only help the nurse to re-discuss the details of every intervention but it also offers other members of the healthcare team, who may be involved in the patient care management, reasons for executing certain procedures. It also ensures that the patient receives proper care as well as therapies from different people thus making it effective.
List of nursing care plans and examples.
Free examples are particularly important for a nursing care plan if a person has no idea how to start compiling it. All these are examples that when followed can help anyone who wants to go through the entire process from the assessment of the issue to the evaluation of that particular issue. From these examples, you can get the different ways that one can develop a care plan, the ways of setting goals, and the ways of selecting intervention.
Conclusion:
Developing knowledge about writing a nursing care plan is important because it provides quality patient care. It outlines the goal when it comes to treatment whether it is basic complaints such as asthma, high blood pressure, or other complications such as low self-esteem that develop depending on a situation. It can be seen that when using a nursing process for matter and including clear reasons behind each intervention, it can provide the very best result for the patient.
