Nursing Care Plans Diagnoses Interventions And Outcomes PORTABLE Free Download

Nursing care plan formats are usually categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. Some agencies use a three-column plan where goals and evaluation are in the same column. Other agencies have a five-column plan that includes a column for assessment cues.

The first step in writing a nursing care plan is to create a client database using assessment techniques and data collection methods (physical assessment, health history, interview, medical records review, and diagnostic studies). A client database includes all the health information gathered. In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formulate a nursing diagnosis. Some agencies or nursing schools have specific assessment formats you can use.

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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 involves establishing a preferential sequence for addressing nursing diagnoses and interventions. In this step, the nurse and the client begin planning which of the identified problems 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.

Matt, this page is very informative and I especially appreciate seeing care plans for patients with neurological disorders. I notice, though, that traumatic brain injury is not on your list. Might you add a care plan page for this?

The most comprehensive nursing care planning book available, Nursing Care Plans, 7th Edition features more than 200 care plans covering the most common medical-surgical nursing diagnoses and clinical problems. As in past editions, authors Meg Gulanick and Judith Myers meticulously updated content to ensure it reflects the most current clinical practice and professional standards in nursing, while still retaining the easy-to-use, reader-friendly format that make this book so unique. Functioning as two books in one, it provides you with both a collection of 68 nursing diagnosis care plans to use as starting points for creating individualized care plans and a library of 143 disease-specific care plans for medical-surgical conditions most frequently encountered in nursing practice.

"Covering the most common medical-surgical nursing diagnoses and clinical problems seen in adults, Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 9th Edition contains 217 care plans, each reflecting the latest best practice guidelines. This new edition specifically features three new care plans, two expanded care plans, updated content and language reflecting the most current clinical practice and professional standards, enhanced QSEN integration, a new emphasis on interprofessional collaborative practice, an improved page design, and more"--Publisher.

Nursing care plans are an essential tool in the nursing process to create continuous and individualized care. Nursing care plans help nurses clarify care goals and prioritize interventions for both short and long-term goals of care. As part of the nursing process, the care plan is created after the nurse has identified a nursing diagnosis. A nursing diagnosis supports the care plan and outlines appropriate interventions. Nursing diagnoses should align with a NANDA-I nursing diagnosis, creating consistency in nursing diagnosis terminology and facilitating effective communication.1 Overall, a care plan is an essential tool for communication between nurses and other care team members so that high-quality, continuous, evidence-based care is provided.

1. Follows the client from admission to discharge

Care plans can be used to continually update care goals during an interaction. This includes care provided across settings, including community, acute, or residential settings.

3. Measures outcomes of interventions

Care goals and interventions related to those goals are clearly laid out in the plan of care. In addition, the care plan provides a roadmap to determine if the interventions provided have addressed the care goals.

5. Coordinates other disciplines

The care plan may include input or interventions other interdisciplinary team members provide. A care plan communicates priorities between interprofessional team members to coordinate on common goals.

7. Documentation purposes

Care plans are an opportunity for nurses to demonstrate that safe and ethical care was provided in accordance with professional regulations. Documentation may be used for communication, quality improvement, research, or legal proceedings.

Formal care plans are documented as part of the patient record used to coordinate, prioritize, and maintain continuity of care. While formal care plans are also modifiable depending on new priorities or the outcomes of interventions, they are often related to the longer-term goals of the patient. The formal care plan might include goals to meet before discharge from the hospital or the service. Both formal and informal care plans are used within the framework of the nursing process.

Care plans can be either standardized or individualized for the individual patient. Many care settings will use standardized care plans for specific patient conditions to ensure consistent care is delivered. One example of a standardized care plan is the post-operative care pathway used in post-surgical units. These post-operative care plans outline expected goals for each post-operative day. However, standardized care plans should be tailored when possible to the needs of the individual patient.

3. Planning: Time to create goals

In step three of the nursing process, the nurse, ideally in collaboration with the patient, creates goals of care based on the nursing diagnosis. A care plan, including expected outcomes, is created to achieve these goals. A nursing care plan is essential for this phase of the nursing process because it directs interventions and how outcomes will be measured.

4. Implementation: Time to act

In the implementation phase of the nursing process, the nurse implements the interventions described in the care plan to achieve the goals of care. The nurse uses their knowledge, experience, and critical thinking to decide what interventions are a priority. Often, interventions are based on orders from the physician.

5. Evaluate: What are the outcomes?

In the evaluation phase of the nursing process, the nurse reassesses the patient to determine if the intervention has the desired outcome. Next, the nurse should evaluate if the goals of care have been met or require more time. If the intervention does not have the desired effect, the nurse should consider if the care plan needs revision or if the goals of care need to be updated.

The nurse assesses the client who was in a motor vehicle accident. The client reports a pain level of 9/10 in their right shoulder. Through an x-ray, the client is determined to have a dislocated shoulder, and the nursing diagnosis of acute pain is applied. The nurse begins planning treatment and goals to reduce pain and instill comfort. The nurse administers IV pain medication as ordered and supports the right arm with pillows. The nurse evaluates the effectiveness of interventions by asking the client to rate their pain on a scale of 0-10. Depending on the outcome, the nurse may determine that the intervention was successful or requires revision.

Overall, the care plan should flow seamlessly as part of the nursing process, taking into account relevant nursing diagnoses, expected outcomes, and the effectiveness of the planned interventions. If necessary, goals are revised, and the care plan is repeated until goals are met or are no longer applicable.

While rationales are not included in traditional nursing care plans, they are used in student care plans. When learning to write care plans, adding the rationale behind the diagnosis and interventions can be helpful. Students can explain the pathophysiology behind their assessment and why their intervention is necessary to guide their understanding.

Dependent: Dependent nursing interventions require the participation of another health professional to carry out the intervention. Dependent interventions are often ordered by physicians and then implemented by nurses. Collecting blood work that a physician has ordered is an example of a dependent nursing intervention.

Collaborative: Collaborative nursing interventions are carried out with other healthcare professionals through collaboration or consultation. Collaborating with a physical therapist on exercises to improve patient mobility is an example of a collaborative nursing intervention.

The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to acute pain.

2. Ask the patient for feedback.

Feedback can enhance the pain care plan. Ask the patient to evaluate and report the effects of the pain interventions in a patient with acute bronchitis.

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