Page 12 - Advanced Communication in Nursing

Reading

Reading texts about a how to develop an write nursing care plan

a.
Read the text and fill the blanks to complete the summary.

DEVELOPING A NURSING CARE PLAN

Nursing care plans are a vital part of the nursing process. They provide a centralized document of the

patient’s condition, diagnosis, the nursing team’s goals for that patient, and measure the patient’s

progress. Nursing care plans are structured to capture all the important information for the nursing

team in one place.

The information and the updates are centralized to make sure that everything important is documented

and available to all team members. Thus, the patient education will be much easier because all nursing

staff members know and are able to reinforce what the patient needs to learn.

Nursing plans should be holistic and take account of nonclinical needs where possible, such as

preferences for chaplain services or other ways to support the patient’s mental well-being.

1. Patient Assessment

Patient assessment includes a thorough evaluation of subjective and objective symptoms and

vital signs. Nurses are responsible for collecting and maintaining this data, although certified
nursing assistants may help collect vital signs.

2. Nursing Diagnoses
A nursing diagnosis is based on the subjective and objective data collected during the patient
assessment. The nursing diagnosis is separate from a medical diagnosis which must be provided

by a physician or nurse practitioner. Nurses select standardized diagnoses approved by the
North American Diagnosis Association (NANDA) and Indonesian Standardized Nursing Diagnosis
(SKDI) that are relevant to the patient’s condition, symptoms, and risks.
3. Anticipated Outcomes/ Goals
This part describes the goals for the patient, usually both short-term goals, such as reduction

of pain or improvement in symptoms or vital signs, as well as long -term goals, such as recovery

within a certain time frame. The goals are directly related to the nursing diagnosis.
4. Implementation/ Intervention

It describes how the nursing team can work to achieve the goals. Specific nursing intervention
are planned based on the goals. This section also documents what nursing-specific care the
nursing team has performed for the patient.

5. Evaluation
This section describes how well the patient’s condition responded to the nursing interventions
or, in other words, how the goals were or were not met. If the goals were not met, the nurse
revises the plan. If the goals were met, the nurse may decide to add more goals and

interventions.

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