Nursing Care Plan

Nursing Care Plan

Nursing Care Plan gives direction on nursing care required by either a family or individual or community. It aims at facilitating a holistic care, as well as standardized evidence. It is not a new concept since it has been used over the years by the veterinary profession. The component of the nursing care plan includes diagnosis, interventions, assessment, expected outcomes, evaluation as well as the rationale. There are reasons why we need to document a care plan as a   process. It provides actions that need to be addressed by the nurse to support nursing diagnosis through the nursing assessment. It also provides for interventions to be used together with their implications. This plan has a sense of continuity of safety, care, quality as well as compliance. This care plan ensures proper documentation and reimbursement in cases of medical insurance (Taylor, 2011). In this thesis, I shall create a care plan from a case study while highlighting various activities to be taken at each stage of the component.

The objective of executing the nursing care plan includes ensuring that we have an evidenced-based nursing care as well as make it comfortable together with making the process well familiar in hospitals. Secondly, it shall provide holistic care that is the individual is considered wholesomely including psychological, physical, spiritual and social with regards to prevention of disease as well as management. It also establishes a care pathway together with care bundles. Care pathways provides a mechanism in which teamwork prevails through consensus about expected outcome and standards of care while care bundles initiate the best practice about care provided for a given disease. It also helps in recording and measuring care.

A care plan should have the following components; client assessment, medical result and diagnostic reports. It is the initial stage of creating a nursing plan. It is composed of the following areas as well as abilities: emotional, physical, sexual, cultural, psychosocial, cognitive, spiritual, functional, age-related, environmental and economic. It is categorized as objective or subjective. Short or long term outcomes are outlined for the expected patient. Documentation is provided for the nursing interventions. It gives a rationale for intervention thereby making it evidence-based care. It ensures evaluation through documentation of the outcome of nursing interventions.

Today nursing care plan is computerized. It is a digital form of inputting a care plan as opposed to handwritten. It gives the necessary element of the nursing process. With the invention on computerized cares plan, it has increased documentation of associated factors, signs, and symptoms as well as nursing intervention. With the system in place, it makes it more accessible, accurate, easier to edit and complete as compared to the handwritten as well as the preprinted care plan.

Case study

Mr. Gray is an 86 year old male that was admitted to the hospital four days ago after falling at home.  He was diagnosed with a right hip fracture and underwent an ORIF of the right hip three days ago.  He has an IV to his right hand with minimal erythema and edema.  He has a Foley catheter draining cloudy, amber-colored urine. His right hip incision is intact with staples with minimal bloody drainage.  His last bowel movement was five days ago before his admission to the hospital.  He reports having to use a laxative frequently to have a bowel movement at home.  He has not been up and walking since his surgery.  Physical therapy is working with him on ambulation today.  Bowel sounds are hypoactive in all four quadrants.  His abdomen is soft and slightly distended.  He hasn’t been eating very well over the last several days and has had an inadequate intake of fluids. Vital Signs:  132/76    96    20   101.9. WBC count 12,500

To execute the care plan, we shall adopt a five-stage process that includes the collection of information, analyze all the information given to find out what areas the patient is in trouble thereby require action then provide the possible solution to improve the patient’s problem. The third step is to think about the information whether it is subjective or objective to come up with intervention and evaluation. The fourth step shall require translation from NOC textbook to look for official terms as illustrated for the problems and jot them down as well as align outcomes and intervention. The fifth stage will include transcribing care plan.

 Patient-Centered Care Plan

Student’s Name:_________________________________ Age:____86__ Sex:_M____ Room No. ________
Patient’s Initials:_G________________________ Long-term Goal: ______________________
Medical Dx: ____________________________ ____________________________________
Surgical Dx: ____________________________ ____________________________________
Admitting Dx:__________________________ ____________________________________
  ASSESSMENT ANALYSIS PLAN

 

IMPLEMENTATION EVALUATION  
  Data Collection

Subjective & Objective

Nursing Diagnosis Patient-centered Goals

Measurable Outcome

Nursing Orders/Action Include Rationale & References Evaluate Each Outcome Criterion & Make Recommendations  
 
  • 86 years old
  • Admitted to the hospital four days ago
  • Last BM 5 days ago • Frequent laxative use at home
  • Poor activity
  • Bowel sounds hypoactive in all four quadrants
  • Abdomen soft and slightly distended
  • Poor PO intake
  • Poor fluid intake

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

constipation

The patient will be free from constipation by 31/08/2016 as evidenced by:

  1. Fewer bowels sound hypoactive in all four quadrants.
  2. Good po intake
  3. Proper fluid intake
The Student will perform on 0700-1800 shift on 24/08/2017:

1a.Take blood tests to check on hormone levels for four-hour 0800-1100

Rationale…citation

2a.Carry a Barium studies to look for any blockages in your colon for two-hour 1100-1300

Rationale…citation

2b.Complete colonoscopy to search for blockages in your colon for one hour 1300-1400

2c.Ensure he eat a well-balanced diet with plenty of fiber for seven days

Rationale…citation

3. Ensure that the patient drinks 1 1/2 to 2 quarts of water as well as other fluids per day beginning immediately.

Rationale …citation

 

Overall goal met

 

1.      0800 Blood sample taken

1100 Blood tested positive

Criteria met

2.      1100 Barium study initiated

1300 Barium study shows no blockage of colon

1300  Colonoscopy is initiated

1400 Colonoscopy shows blockage of colon

Criteria met

3.      Balanced diet and fluids administered.

 

Criteria met

 

 

 

 

References

Taylor, C. (2011). Fundamentals of nursing: The art and science of nursing care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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