FORMULATION OF CARE PLAN

BY:- Firoz QureshiDept. Psychiatric Nursing

The nursing care plan is written guide that organizes information about a client’s care into a meaningful whole .

It includes the actions nurses must take to address the clients nursing diagnosis and meet the stated goals .

INTRODUCTION

A plan ,based on nursing and assessment and a nursing diagnosis ,carried out by a nurse .

DEFINITION

A plan ,based on nursing and assessment and a nursing diagnosis ,carried out by a nurse .

To provide direction for individualized care of the client .

To provide for continuity of care To provide direction about what needs to be documented on the client ‘s progress notes

To serve as a guide for assigning staff to care for the client .

PURPOSES

A nursing plan of care documents the problem solving process.

A nursing care plan outlines the nursing care to be provided to an individual /family /community it is a set of actions the nurse will implement to resolve /support nursing diagnosis identified by nursing assessment .

WRITING A NURSING PLAN OF CARE

The plan is a critical element in focusing nursing activity .

To serve as evaluation criteria and meet the standards of the joint commission for accreditation of health care organizations (1996).

CONT…...

The plan of care is nursing centered

The plan of care is a step by step process .

TWO IMPORTANT CONCEPTS GUIDE A NURSING PLAN OF CARE

What is a care plan.Why do nurse write care plansWhat are the different parts of a care plan

What other paper work will I need to know

How am I evaluated

NURSE WORK

Provide a direction for individualized patient care.

Provide continuity of care for the patient with all hospital departments.

Provide documentation on patient and family needs.

NURSING CARE PLAN

Sufficient data are collected to substantiate nursing diagnosis .

At least one goal must be stated for each nursing diagnosis .

Outcome criteria must be specifically designed to meet the identified goal .

Each intervention should be supported by a scientific rationale .

A STEP-BY STEP PROCESS IS EVIDENCED BY THE FOLLOWING

Evaluation must address whether each goal was completely met or ,partially met .

CONT….

1.Date and sign the plan .2.use the category headings3.Nursing Diagnosis 4. Goals /Outcome Criteria 5.Nursing Orders Criteria 6.Evalution and include a date for the

evaluation of each goal .7.Use standardized medical or medical

symbols and key words rather than complete sentences to communicate your ideas.

GUIDELINESS FOR WRITING NURSING CARE PLAN

Refer to procedure books or other sources of information rather than including all the steps on a written plan .

Tailor the plan to the unique characteristic of the client by ensuring that the client choices ,such as preferences about the time of care and the methods used are included .the reinforces the clients individually and sense of control .

CONT….

Ensure that the nursing plan incorporate the preventive and health maintenance aspects as well as restorative .

Ensure that the plan contains orders for ongoing assessment of client .

Include collaborative and coordination activities in the plan.

Include plans for the client discharge and home care needs .

CONT…..

As you care for people in various health care facilities ,you will discover a variety of nursing care plan formats .

TYPES OF NURSING CARE PLANS

1. STUDENT NURSING CARE PLANS 2.TEACHING PLANS 3.CASE MANAGEMENT CARE PLANS

4.COMPUTERIZED NURSING CARE PLANS

Provides acuity for staffing needs.Provides reimbursement for insurance which was started by Medicare and Medicaid and now used by all insurance companies. This is how hospitals and patients receive payment.

CARE PLAN

Related NANDA Nursing Diagnoses• Ineffective Role Performance• Body Image Disturbance• Chronic low self‐esteem• Self‐esteem disturbance• Situational low self‐esteem• Personal Identity disturbance

NURSING DIGNOSIS

Begin with a complete assessment of your patient. Get as much information as possible from the chart, such as lab data, x-ray reports,

physician history and physical exam

HOW TO WRITE NURSING CARE PLAN

Subjective-This is what your patient tells you.

“ My head hurts” States on scale of 1-10 My head hurts at 8.Objective- This is what you see.Patient rubbing head.

DATA COLLECTION

This helps you decide what is really wrong with your patient. You must listen to know what they are not telling you.

TALK TO YOUR PATIENT

It is not a medical diagnosisA nursing diagnosis is the plan of care for your patient which all member of the staff will follow as they care for the patient.

NURSING DIAGNOSIS

What are you going to do to help your patient reach their goal. This is what you do daily for your patient. If you give your paper to a peer would they be able to follow your intervention or plan of care.

INTERVENTION

This is the scientific reason you did this for your patient. You must tell us (cite) where you got your information. This could be your from your books or a reliable internet source.

NURSING RATIONALE

Did your patient reach their goal in the time frame that you allowed for them

Did your patient not reach their goal and do you need to extend the timeframe or is this an unreachable goal and you need to start over?

EVALUTION

We have covered every aspect of this paper

This is the form you will turn in daily and it will help you write your care plan

This form will be given to you on Friday after clinical. If your instructor is very busy, you will receive it on Monday.

PAPER WORK IN CARE PLAN

EXAMPLE OF NURSING CARE PLAN