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Download the care plan template of your choice now! It is used to coordinate the care given to the patient by different members of the health care team. NANDA nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems.
Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses. Setting priorities is the process of establishing a preferential sequence for address nursing diagnoses and interventions.
In this step, the nurse and the client begin planning which nursing diagnosis requires attention first. Diagnoses can be ranked and grouped as having a high, medium, or low priority. Life-threatening problems should be given high priority. Involve the client in the process to enhance cooperation. After assigning priorities for your nursing diagnosis, the nurse and the client set goals for each determined priority.
Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement.
One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are often used interchangeably. Goals and expected outcomes must be measurable and client-centered. Goals are constructed by focusing on problem prevention, resolution, and rehabilitation.
Goals can be short-term or long-term. Long-term goals are often used for clients who have chronic health problems or live at home, in nursing homes, or in extended-care facilities. Goals or desired outcome statements usually have four components: a subject, a verb, conditions or modifiers, and criterion of desired performance. When writing goals and desired outcomes, the nurse should follow these tips:. Nursing interventions are activities or actions that a nurse performs to achieve client goals.
Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step. Rationales, also known as scientific explanations, explain why the nursing intervention was chosen for the NCP. Rationales do not appear in regular care plans.
They are included to assist nursing students in associating the pathophysiological and psychological principles with the selected nursing intervention.
Evaluation is an essential aspect of the nursing process because conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed. Different nursing programs have different care plan formats.
Most are designed so that the student systematically proceeds through the interrelated steps of the nursing process, and many use a five-column format. They are segmented into categories:. Nursing care plans about the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:. Nursing care plans about the different diseases of the cardiovascular system :. Care plans NCP covering the disorders of the gastrointestinal and digestive system :.
Care plans related to the reproductive and urinary system disorders:. You can also divide this up into subjective and objective data. Now, the second column of the nursing care plan template is where the nursing diagnosis goes. This is a FULL nursing diagnosis: including the NANDA International standardized nursing diagnosis, the related to factor, and the as evidenced by section, which is your supporting assessment data.
That will be an affiliate link, so I will receive a small commission if you decide to purchase through that link, so thanks for that, your support means the world to me! So whatever evidence you gathered during your assessment that supports your nursing diagnosis, write those down here in the as evidenced by section of the nursing diagnosis.
Now, here is where things get sticky for a lot of nursing students. This is where you write your patient goals or outcomes, so what do you want the patient to achieve.
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