Complete Care Plan
Associated care plan completed
None -- done
Additional research, collaboration, consultation.
Additional Risk Factors
Very specific evaluation
Collaborative or nursing issues that are important but may, by necessity, be delayed
Priority identification -- anticipate problem prior to formalizing plan
Review, Revise, Assess
Fluid and continuous
Depending on treatment outcome
Surgery or treatment may accentuate
(Carpenito-Moyet, 2009, 25-31)
Process and Planning -- The nursing care plan is a guide, but is meant to be fluid and responsive to the patient's individual needs, issues, and potential emergencies. Both subjective and objective data are collected, and then organized into a systematic plan. This helps each member of the healthcare team glean the appropriate information at any time. More important, it allows the charge nurse to identify and comment on specific areas of concern in order to avoid future problems whenever possible. The basic PES Nursing Diagnosis is used (Problem, Etiology, Signs and Symptoms). Then expected (and potentially unexpected) outcomes and goals are explained in as much detail as necessary....
Once this initial goal is set, nursing interventions must be clearly delineated. This will assist the client in recovery, and also provide a guide for any additional therapies that become appropriate. It is essential that this section be specific so that anyone reading the plan can assist if necessary. Finally, additions to the plan, since it is fluid, such as "at risk," or "maintaining wellness" may be added as needed (Gulanick and Myers, 2007). This revision is a key paradigm throughout the process -- revision of expected outcomes based on the individual's response to medical care.
REFERENCES
Barrett, Wilson and Woollands. (2009). Care Planning: A Guide for Nurses. Pearson Education.
Brown, C. (2007). "Where are the Patients in the Quality of Healthcare?" Editorial in International Journal for Quality in Healthcare. 19(3): 125.
Burkhard, M., et.al. (2007). Ethics and Issues in Contemporary Nursing. Delmar Cenage.
Carpenito, L. (2009). Nursing Care Plans and Documentation. Kluwer Health.
Doenges, M. et.al. (2002). Nursing Care Plans: Guidelines For Individualizing Patient Care.
F.A. Davis.
Gulanick, M. And J. Myers. (2007). Nursing Care Plans: Nursing Diagnosis and Intervention.
Mosby.
