In nursing school , there is probably no more hated than allocation plan nursing class. They are assigned to each type of class, for patients in intensive care, in mental health and even to community care. Nursing students stay up all night preparing specific plans of care for each patient to clinic the next day, but which tool is the induction of this agony still used so universally ?
The purpose of the Written Care Plan
The care plans guided by individualized customer attention. A care plan flows from the single list of each patient 's diagnosis and should be organized according to the specific needs of the individual .
Continuity of care. The care plan is a means of communication and organization of the actions of a nursing team in flux. As the needs of the patient to attend the updated plan is transmitted to the nursing staff at shift change and during nursing rounds .
Care plans help teach documentation. The care plan must specifically describe what observations to make , what nursing actions to perform , and the instructions of the client or family members required.
They serve as a guide for the allocation of staff to serve customers . There may be aspects of patient care that should be assigned to team members with specific skills .
Care plans serve as a guide for refund. Medicare and Medicaid originally set the plan into action , and other third-party insurance companies followed suit. The history is used by insurance companies to determine what they will pay in connection with the hospital care received by the client . If nursing care is not accurately documented in the care plan , there is no evidence the care was provided . Insurers do not pay for what is not documented .
The purpose of the creation of care plans is to help students to pull information from many different scientific disciplines as they learn to think critically and use the nursing process to solve problems. As a nursing student writes more plans , the ability to think and process information as a nurse to be more effective in their practice rooted .
Care plan formats
The exact format for a nursing care plan varies slightly from place to place . They are usually organized by four categories : nursing diagnosis or problem list, objectives and performance criteria ; nursing orders , and evaluation.
As defined by the North American Nursing Diagnosis Organization International (NANDA -I) , nursing diagnoses are clinical judgments about individual , community or potential experiences or responses to family or health problems or life processes . A nursing diagnosis is used to define the appropriate plan of care for the customer and drives interventions and patient outcomes .
Nursing diagnoses also provide a standard nomenclature for use in electronic medical records (EMR ) , allowing clear communication between team members care and data collection for continuous improvement in patient care .
The nursing diagnoses are different from medical diagnoses. A medical diagnosis - which refers to a disease process - is performed by a physician and be a condition that only a doctor can treat . By contrast, a nursing diagnosis describes the physical response , socio- cultural, psychological and spiritual of a client for a potential disease or health problem. During the time that a disease is present, the medical diagnosis never changes, but a nursing diagnosis evolves changing customer responses .
The goal set by nursing care plan - in terms of observable client responses - what the nurse is expected to achieve by implementing nursing orders . This is a result or change in the status of the desired client. The terms objective and outcome are often used interchangeably , but in some nursing literature , a goal is intended as a general statement , while the result is more specific. For example, a goal might be that the nutritional status of patients improve in general, while the result would be that the patient will win five pounds before a certain date.
Nursing orders are instructions for specific activities to be undertaken to help the patient achieve the goal of health care . The level of detail of the order is dependent health personnel who will carry out the order. Nursing orders will all contain:
- date
- An action verb as " Monitor" , " instruct" , " feel " , or something equally descriptive
- A content area is where and what order , for example, the placement of a " spiral bandage on his left leg from ankle to below the knee "
- A time element define how long or how often nursing action occurs
- Signature of nurse prescribing , as the orders are legal documents .
- Finally, evaluation, health professionals determine client progress toward achievement of objectives and the effectiveness of nursing care plan . Evaluation is very important because it determines whether nursing interventions must be completed , continue or change.
Care plans teach nursing students how to think critically , how to care for patients on a more personal level, not as a disease or diagnosis . They help to teach how to prioritize care and interventions. They are a necessary evil in the nursing school, tried and true for teaching future nurses who did not care , but how to provide care that will improve the health status of the client.
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