Nursing care plans help track a patient's progress through the recovery process. These plans give nurses a specific set of goals to measure the patient's progress leading to the eventual patient discharge. Care plans provide a thorough accounting of the patient and his care from beginning to end.
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Take a comprehensive patient assessment. This includes all the objective information, such as age, date, sex and vital signs. It also includes subjective patient information, such as symptoms and medical history.
Create a problem list that includes the medical diagnoses and all issues affecting treatment and patient's care, such as family problems, eating habits and disabilities.
Write a plan of care. This plan includes specific goals and instructions for patient care. These goals should be measurable and realistic for the patient --- i.e., being able to keep down solid foods, ability to walk a certain distance and ability to formulate sentences. All of these goals will be dependent on a) the type of patient and b) the course of care.
Evaluate the patient per shift. This will be done by the different nurses caring for the patient and reporting all the evaluations of the patient's progress. This evaluation consists of any progress or decline in the patient's status.
Document all the drug and fluid requirements of the patient. These drugs and the times given can affect how the patient responds to various treatments. Adjust the schedule, as necessary, to allow for unfavourable drug interactions.
Re-evaluate the goals, as necessary. As assessments are updated, goals need to be modified to accommodate for the increasing or decreasing abilities of the patient.
Tips and warnings
- Care plans should also cover all outside department interventions; goals can be set for these factors as well, including physiotherapy and respiratory therapy.
- Drugs should be mapped in the care plan and followed for how the drugs affect the patient and the outcomes.
- Goals should also be set for the patient's discharge. This will aid the patient in his recovery when he returns home. These goals must be realistic and set in simple language, so that the patient is more likely to comply with the requirements.
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