Each nursing care plan is an individualised plan based on the patient's needs at the time of illness. Every disease and condition process deserves a care plan. Following this care plan is important and could save someone's life.
The typical nursing care plan consists of determining a patient's health care problem, an approach or treatment, a goal or expected outcome, and the actual result. Some care plans are designed with the SOAP format, which means Subjective, Objective, Assessment and a Plan by the nurse.
An example of a typical patient health care problem would be shortness of breath related to chronic obstructive airway disease. In this case, the approach or treatment would be ventolin nebuliser treatments every 4 hours as needed. This will be ordered by the doctor in charge of the patient. The goal would then be that the patient will remain as comfortable as possible during the treatment and in the end be free from shortness of breath.
SOAP Care Plan
The SOAP care plan is designed with several things in mind. The Subjective is what the patient is complaining of in this case. The Objective is what the nurse is observing at that time. Assessment is the actual nursing assessment performed such as listening to lung sounds and counting of respirations. The Plan is the treatment, such as the ventolin nebuliser treatment.