1. CARE PLANS

2. DEFINITION A nursing care plan outlines the nursing care to be provided to a patient.nursing care It is a set of actions the nurse will implement to resolve nursing problems identified by assessment.assessment Care plans are formed using the nursing process.nursing process

3. CHARACTERISTICS It focuses on actions which are designed to solve or minimize the existing problem. It is a product of a deliberate systematic process. It relates to the future. It is based upon identifiable health and nursing problems. Its focus is holistic.

4. COMPONENTS The nursing care plan may consist of a NANDA nursing diagnosis with related factors and subjective and objective data that support the diagnosis. NANDAnursing diagnosis Nursing outcomes (or goals) to be achieved including deadlines. Nursing interventions with specific actions

5. Step 1 Collecting subjective data and objective data.subjectivedataobjective data Subjective:what the patient tells you, c/o, s/s Objective: information based on assessments; what you see, hear, smell etc.

6. Step 2 Organize the data into a systematic pattern, such as Marjory Gordon's functional health patterns functional health patterns This step helps identify the areas in which the client needs nursing care.

7. Step 3 Based on Gordon’s, then make a nursing diagnosis.nursing diagnosis Nursing diagnosis also includes the relating factors and the evidence that supports the diagnosis

8. Diagnosis Example Ineffective Airway Clearance r/t tracheobronchial infection (pneumonia),

9. Step 4 State the expected outcomes, or goals A common method of formulating the expected outcomes is to reverse the nursing diagnosis, stating what evidence should be present in the absence of the problem. Must be measurable, specific date, or level achieved

10. Outcomes Example Effective airway clearance as evidenced by normal breath sounds; no crackles or wheezes; respiration rate 14-18/min; and no cough by 10/17/07.

11. Step 5 Interventions must be specific, How often it is to be performed, so that any nurse or appropriate faculty can read and understand the care plan easily and follow the directions exactly.

12. Intervention Example Instruct and assist client to TCDB ( to assist in loosening and expectoration of mucous) every 2 hours

13. Step 6 Evaluation is made on the goal date set. Goal met or not? Plan of care modified, discontinued, or continued.