Nursing care plan

Q- why nursing care plan is needed ? 

Ans- Nursing care plan useful in providing a 

         Right pathway to a nurse to provide care to 

          The patients come under her care . 

IN TOTAL THERE ARE SEVEN STEPS INVOLVED IN MAKING A NURSING CARE PLAN 

• Assessment 
• Nursing diagnosis 
• Goal 
• Planning 
• Rationale 
• Implementation/intervention 
• Evaluation 

Now there is the brief description of all the steps 

                    1- Assessment 

Assessment means how do a nurse assess the condition of patients or observe the patients in this step the nurse collect all the data of patient condition for interventions 

There are two ways of collecting the data

- subjective data 

-objective data 

SUBJECTIVE DATA- 

subject means self or the patient ....so by the subjective data means the data which is given by the subject or the patient 

   Example- patient said that I'm having abdominal pain 

Means all information which is verbalize by the patient itself 

OBJECTIVE DATA- 

Objective means all the things observed by the nurse in the patient .

  Example- nurse checked the patient's vitals and found the temperature is 101°f  

That is objective data 

 

              2- Nursing diagnosis 

Nursing diagnosis should not be mess with medical diagnosis like appendicitis 

While making a nursing diagnosis learn two things 

First is related to - what is the reason behind patients condition like if patient says I'm having difficulty on breathing than what is the reason of difficult breathing like it may be related to excessive secretion of mucous which occluded air passage 

Second is evidenced by - evidence is how the nurse come to know patient is developing any condition .

Evidence is the patients symptoms like difficult breathing , palpitations , or the patients verbalization 

                3- goal 

Goal is why we are providing the care to the patient what is the reason 

There are two parts involved in the goal 

SHORT TERM GOAL 

Short term goal is for the short interval for the immediate relief of symptoms 

Like if patient is having difficulty breathing 

In this condition the nurse immediately check the spo2 and according to the readings of spo2 provide the oxygen therapy or the nebulization to the patient 

To comfort the patient for that particular time 

LONG TERM GOAL 

long term goal includes the cure of illness permanently 

                  

                    4 - planning 

Planning is the important step of Nursing care plan because in this step the nurse plans all the care to be provide to the patient 

                    5- Rationale 

Rationale is directly related to planning whatever the nurse plan for the patient it should be only patient priority based and each step should be rationalised 

Like if the nurse is providing the oxygen therapy to the patient she should know the rationale behind it and the outcome of the oxygen therapy 

                    6 - Implementation 

All those things nurse planned to provide the patient is to be implemented properly according to the condition of patient and need of the patient 

                   7- Evaluation 

Evaluation is the last step of Nursing care plan but not of the nursing care 

In this step the nurse evaluate the patient condition and compare with the condition before the implementation of Nursing interventions 

It can be assess by observing the patient in case patient is unconscious 

And by the patients verbalization

Assessment	Nursing  Diagnosis	goal	planning	rationale	implementation	evaluation
SUBJECTIVE DATA  Patient said that I'm having difficulty in breathing  OBJECTIVE DATA  I observed through patients respiratory rate -32 breaths min	ineffective breathing pattern related to excessive secretion of mucous as evidenced by mucous in cough ,  Increased respiratory efforts	short term goal  To relax the patient  To meet oxygen demand of body  Long term goal  To relieve the breathing problem permanently	assess the general condition of the patient - provide Fowler's position to the patient  - monitoring the vital signs of patient  - provide oxygen therapy to the patient	to get the baseline data of patient condition for Nursing interventions  So that lungs will get area for expansion and air exchange  - to know any fluctuations in vital signs - to meet the oxygen demand of body	patient's condition is assessed for difficulty breathing  Fowler's position is provided to the patient  Vitals monitored every 2 hourly  - oxygen therapy provided to the patient	patient condition is improved  Respiratory rate is 24 breaths minute

The above given table is an example of how to make nursing care plan