Nursing Care Plans Diagnoses, Interventions, and Outcomes
It takes a logical approach to complete a nursing care plan appropriately. Having a good care plan will help you to communicate between nurses, patients, and other healthcare providers so that you can achieve your healthcare goals.
Therefore, the quality and consistency of patient care will be compromised without a good nursing care planning process. During a patient’s stay in the health care facility, the nursing care plan is updated frequently in response to changes in the patient’s condition and evaluation of progress toward goals.
Different types of nursing care plans
There are two types of nursing care plans: informal and formal. In informal nursing care plans, a nurse’s strategy for action is created in her mind. On the other hand, a formal nursing care plan is a written or computerized document containing information about how the patient will be treated. There are two types of formal care plans: standardized and individualized.
In a standardized care plan, the nursing needs for a group of patients with everyday needs are described. Personalized care plans are designed to address the unique needs of a particular patient or those that are not addressed by standard care plans.
Various components
Nursing care plans typically include nursing assessment, nursing diagnoses, planned goals and expected outcomes, nursing interventions, and rationales. This post, however, focuses on only three components, which are diagnoses, interventions, and outcomes.
Diagnosis
Nursing diagnosis involves taking all the information from the assessment component of a patient’s nursing care plan into account to determine the patient’s condition and medical needs. To diagnose a patient, a nurse must make an informed judgment about the patient’s possible or actual health condition. Multiple diagnoses can sometimes be made for one patient.
Types of Diagnosis
There are four types of diagnosis; they are;
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Actual – Problem-focused
During the nursing assessment, the nursing team determines the patient’s actual or problem-centred diagnosis. The diagnosis is based on the presence of related signs and symptoms. Nevertheless, problem-focused nursing should not be seen as more important than risk diagnosis. More often than not, risk diagnosis is the one with the greatest impact on the patient. Nursing diagnosis, related factors, and defining characteristics are used to make a diagnosis.
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Risk nursing diagnosis
The nursing diagnoses result from an assessment of the problem in the patient. Despite this, the presence of risk factors indicates that the problem is likely to develop unless nursing intervention is sought. There are, however, no etiology factors for the diagnosis of the risk factor. Risk diagnostic labels and risk factors are components of risk nursing diagnosis.
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Health Promotion
The health promotion diagnosis is a clinical judgment about motivation and desire to enhance well-being. Diagnoses related to transitioning from one level of wellness to the next are mainly concerned with people, families, or communities.
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Syndrome Diagnosis
A syndrome diagnosis is a clinical judgment about a group of problem or risk nursing diagnoses that are predicted to occur as a result of a specific event or circumstance. Diagnostic labels are required only for these diagnoses that are written as one-part statements.
Write a nursing diagnostic section that describes the current health status of an individual and the possible factors that contributed to the status. However, you do not need to include all the diagnostic indicators.
Nursing Outcomes
By implementing nursing interventions, the nurse anticipates achieving certain nursing outcomes. A nursing diagnosis determines what these outcomes will be. Interventions are planned based on outcomes, which serve also as criteria for evaluating patients’ progress. Furthermore, they enable the patient and nurse to determine whether the problem(s) has been resolved.
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Outcomes in the short and long term
Nurses must measure and focus on patient-centred outcomes. By emphasizing prevention, resolution, or rehabilitation, they can be developed more effectively. A short-term outcome is classified as either short- or long-term. While nurses spend the majority of their time taking care of the patient’s immediate needs, most outcomes of acute care are short-term.
In contrast, long-term outcomes are often appropriate for patients who have chronic health problems or reside at home or in nursing homes.
- The term short-term outcomes imply a change in behaviour that can be achieved immediately, usually within a day or two.
- Long-term outcomes: These are those that indicate an objective to be achieved over a longer time, often weeks or even months.
- Discharging planning: This outcome entails identifying long-term outcomes and enhancing ongoing care and problem resolution through physical therapy, home health, and other referral sources.
You should follow the following tips when writing nursing outcomes;
- Describe outcomes based on the patients’ responses, rather than the nurse’s activities
- The nurse should not write outcomes that reflect what she intends to accomplish, but rather what the patient can accomplish
- Use observable, measurable terms when writing outcomes. You should therefore avoid vague language and words that require interpretation on the part of the observer.
- Verify that outcomes are compatible with therapies provided by other health care providers
- It is important to consider the patient’s capabilities, resources, and limitations when determining desired outcomes.
- Only one nursing diagnosis should be used to determine each outcome
- Be sure the patient considers the outcomes important and values them to ensure collaboration.
Interventions in nursing
Actions or activities a nurse takes to achieve a patient’s goal or achieve a desired outcome are nursing interventions. A nursing diagnosis should be reduced or eliminated by the interventions selected. An intervention in risk diagnosis, for instance, should be aimed at reducing the patient’s risk factors.
The types of interventions
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Independent Nursing Interventions
Nursing actions are ones that nurses are licensed to perform based on their sound judgment and skills. As part of these interventions, the healthcare provider may provide comfort, physical care, and emotional support, or refer the patient to other professionals.
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Dependent nursing interventions
Actions taken under the direction or supervision of the physician are included. Medicines, diagnostic tests, intravenous therapy, diet, exercise, rest, or treatment are among them.
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Collaborative Interventions
Nursing interventions involve collaboration between nurses and other healthcare providers, including doctors, dietitians, therapists, and social workers.
It is important to note that nursing interventions should include:
- Achievable with the resources and time available
- Safe and appropriate for the patient’s health, age, and condition
- Similar to other therapies
- According to the patient’s values, beliefs, and culture
- Nursing knowledge and experience are the basis of this program
Nursing care plan diagnoses, interventions, and outcomes are crucial to getting higher grades. Furthermore, you will become a more competent nurse practitioner. Nevertheless, if you need help with writing a nursing care plan with diagnoses, outcomes, and interventions, you can hire a nursing care plan writer.
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