Nursing Care Plans, Diagnoses, Interventions, and Outcomes
- March 16, 2022
- Posted by: admin
- Category: Nursing Care Plans
Nursing care plans, also known as nursing care plans or nursing care plans, are essential tools nurses use to guide the delivery of patient care. They are structured plans that outline the nursing diagnoses, interventions, and outcomes for a specific patient or population. Nursing care plans help ensure that patient receives comprehensive and individualised care based on their particular needs and health status. The nursing diagnoses are derived from a thorough assessment of the patient’s physical, psychological, and social needs and represent the patient’s health problems or conditions. The interventions are the actions the nurse will take to address the nursing diagnoses and achieve the desired outcomes. The outcomes are the expected results of the interventions and provide a framework for evaluating the effectiveness of the care plan. Nursing care plans are essential for delivering quality patient care and improving patient outcomes.
Different types of nursing care plans
Several types of nursing care plans can be used to guide patient care, including:
- Problem-oriented care plans focus on specific health problems or conditions and provide a comprehensive approach to addressing the patient’s needs.
- Function-oriented care plans: These care plans focus on the patient’s functional status and is based on the patient’s ability to perform activities of daily living.
- Disease-oriented care plans: These care plans are focused on the patient’s diagnosis and are based on the principles of the nursing process.
- Care map plans: This care plans use a visual representation of the patient’s care, including assessments, interventions, and expected outcomes, to provide a comprehensive and easy-to-follow guide for patient care.
- Patient-centred care plans: These plans focus on the patient’s preferences and values and aim to provide individualised and patient-centred care.
- Multidisciplinary care plans: These plans involve a collaborative approach to patient care and are based on the input and expertise of multiple healthcare professionals, including doctors, nurses, and other specialists.
- Outcome-oriented care plans: These plans focus on the expected outcomes of patient care and provide a framework for evaluating the effectiveness of the care provided.
The type of nursing care plan used will depend on the patient’s needs and the healthcare setting and may be modified over time as the patient’s condition changes. Regardless of the type of care plan used, the goal is to provide individualised, patient-centred care that promotes positive patient outcomes.
The components of a nursing care plan typically include the following:
- Patient assessment: A comprehensive assessment of the patient’s physical, psychological, and social needs, including a review of their medical history and current symptoms.
- Nursing diagnoses: A list of the patient’s health problems or conditions, based on the assessment data, and identified using a standardised terminology, such as NANDA International (North American Nursing Diagnosis Association).
- Goals and expected outcomes: A statement of the desired results of patient care, including the expected improvement in the patient’s condition.
- Nursing interventions: A list of actions the nurse will take to address the nursing diagnoses and achieve the desired outcomes.
- Evaluation: A systematic process for monitoring and assessing the patient’s response to care and determining the effectiveness of the care provided.
- Documentation: A comprehensive and accurate record of the patient’s care, including assessments, interventions, and outcomes, to support continuity of care and facilitate communication among healthcare professionals.
- Patient and family education: Information and support are provided to the patient and their family to promote understanding of their condition, their care, and what they can do to support their health.
Each component of the nursing care plan is interrelated and contributes to the overall success of the care plan. Therefore, the nurse can provide comprehensive, individualised care that promotes positive patient outcomes by addressing each component.
The nursing diagnosis is a key component of the nursing care plan. It represents the patient’s health problems or conditions and focuses on the care provided. A nursing diagnosis is a clinical judgment about an individual, family, or community response to actual or potential health problems or life processes. The diagnosis is made using standardised terminology, such as NANDA International (North American Nursing Diagnosis Association), and is based on a comprehensive assessment of the patient’s physical, psychological, and social needs.
Examples of nursing diagnoses include:
- Ineffective airway clearance
- Imbalanced nutrition: less than body requirements
- Acute pain
- Risk for infection
- Activity intolerance
- Deficient fluid volume
- Risk for impaired skin integrity
- Sleep deprivation
The nursing diagnosis provides a framework for delivering patient care and helps the nurse identify and prioritize the patient’s needs. By focusing on the nursing diagnosis, the nurse can develop a comprehensive care plan that addresses the patient’s specific health problems or conditions and promotes positive patient outcomes.
Types of Diagnosis
Nursing diagnoses can be categorised into different types, including:
- Actual Nursing Diagnosis: This type of diagnosis is based on a current health problem or condition, such as pain or infection.
- Risk Nursing Diagnosis: This diagnosis is based on the potential for a future health problem or condition, such as the risk for falls or pressure ulcers.
- Wellness Nursing Diagnosis: This type of diagnosis is based on promoting health and wellness and includes diagnoses such as readiness for enhanced self-care or spirituality.
- Syndrome Nursing Diagnosis: This diagnosis is based on a cluster of symptoms that indicate a specific condition, such as acute confusion or acute confusion related to delirium.
- Health Promotion Nursing Diagnosis: This type of diagnosis is based on promoting health and wellness and includes diagnoses such as health-seeking behaviours or readiness for enhanced health.
The type of nursing diagnosis used will depend on the patient’s needs and the healthcare setting and may change over time as the patient’s condition evolves. Regardless of the nursing diagnosis, the goal is to provide individualised, patient-centred care that promotes positive patient outcomes.
Interventions in Nursing
Interventions in nursing refer to the actions and strategies employed by nurses to promote the health and well-being of their patients. These interventions can range from preventive measures, such as health education and disease screening, to therapeutic interventions, such as medication administration and wound care. Other examples of nursing interventions include patient assessment, patient monitoring, and patient advocacy. The selection of nursing interventions is based on the patient’s specific needs and goals of care and may involve collaboration with other healthcare professionals. Overall, nursing interventions play a crucial role in the delivery of patient-centred, evidence-based care.
The types of interventions
There are several types of interventions in nursing, including:
- Health promotion and disease prevention interventions: These include activities that encourage healthy behaviours and prevent the onset of illness, such as health education, immunisations, and lifestyle modifications.
- Assessment and monitoring interventions: These involve ongoing evaluation of the patient’s physical and mental health status, vital signs, laboratory results, and other parameters to ensure early detection and prompt management of any changes.
- Therapeutic interventions: These encompass a range of activities that aim to treat or manage existing health conditions, such as medication administration, wound care, and rehabilitation therapies.
- Comfort and supportive interventions address the patient’s physical and emotional needs, such as pain management, emotional support, and spiritual care.
- Advocacy and care coordination interventions involve advocating for the patient’s needs and preferences, facilitating communication and coordination among the healthcare team, and promoting continuity of care across different healthcare settings.
The specific types of nursing interventions used will depend on the individual patient’s needs and goals of care, as well as the healthcare setting and healthcare team involved in the patient’s care.
In conclusion, nursing care plans are essential tools nurses use to provide patient-centred care that is individualized to the patient’s unique needs and goals. The care plan involves a systematic assessment, diagnosis, planning, implementation, and evaluation process guided by evidence-based practice and clinical expertise. By developing nursing care plans that outline diagnoses, interventions, and expected outcomes, nurses can provide comprehensive and effective care that promotes the health and well-being of their patients. The nursing interventions included in these care plans are critical components of the nursing process. They can include health promotion, disease prevention, assessment and monitoring, therapeutic interventions, comfort and supportive interventions, and advocacy and care coordination interventions. Overall, the nursing care plan is a dynamic and ongoing document that is updated regularly based on the patient’s changing needs and response to interventions, ensuring that care remains patient-centred and effective.