NURSING CARE PLAN A MUST KNOW FOR STUDENTS AND EDUCATORS
The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient. The TNP is the nurse’s responsibility. She’s the only one who can inscribe information and re-evaluate the TNP during the course of treatment of the patient.
This document is used by nurses, nursing assistant and they communicate the directives to the beneficiary attendants. The priority problems or needs are often the diagnoses of the patient and nursing problem such as wounds, dehydration, altered state of consciousness, risk of complication and much more. These diagnoses are around problems or needs that are detected by nurses and need specific interventions and evaluation follow-up.
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The nursing directives can be addressed to nurses, nursing assistants or beneficiary attendants. Each priority problem or need must be followed by a nursing directive or an intervention. The interventions must be specific to the patient. For example, patients with the problem ‘uncooperative care’ can need different directives. For one patient the directive could be: ‘educate about the pathology and the effects of the drugs on the health situation’; for the other, it could be the use of a directive approach.’ It depends on the nature of the problem which needs to be evaluated by a nurse.
A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost.
Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice.
According to UK nurse Helen Ballantyne, care plans are a critical aspect of nursing and they are meant to allow standardised, evidence-based holistic care.
A care plan includes the following components;
- Client assessment, medical results and diagnostic reports. This is the first step in order to be able to create a care plan. In particular client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic and environmental. Information is this area can be subjective and objective.
- Expected patient outcomes are outlined. These may be long and short term.
- Nursing interventions are documented in the care plan.
- Rationale for interventions in order to be evidence based care.
- Evaluation. This documents the outcome of nursing interventions.
- References NANDA international and Omaha system
Nr Danladi Aminu