Written Assignment- Care Plan

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Written Assignment- Care Plan

Written Assignment- Care Plan

You are the nurse receiving report on your patient that was admitted as an emergency earlier in the day. A 64-year-old female underwent a right colectomy. The right side of her colon was removed due to cancer. She has a history of smoking & no other health problems. She is currently being transferred to you in PACU. She has a midline incision with a Penrose drain, a stab wound w/ a Jackson Pratt drain to incision. She also has a NG tube, attached to intermittent suction. She is alert, riented and can move all 4 extremities. BP is 110/68, Respiratory rate is 14, O2 stats are at 93% w/ additional oxygen given via nasal cannula.

All labs are normal. You are asked to change the dressings daily and document the drainage. What precautions will you take to prevent this patient from obtaining a nosocomial infection?

Please answer the questions and develop a care plan for a patient that will be having an elective surgery. Please use the provided format for building your care plan. You will need to use your nursing reference materials as you build this care plan.

Go to ATI website for care plan – go to integration materials – scroll down to active learning templates – choose systems disorder

A nursing care plan (NCP) is a structured method for identifying current requirements and recognizing possible needs or dangers. 
Nurses, their patients, and other healthcare providers communicate through care plans to achieve desired health results. 
The quality and consistency of patient care would suffer if the nursing care planning procedure was not in place.

 

Nursing care planning begins when the client is accepted to the agency and is revised on a regular basis as the client’s condition changes and goal achievement is assessed. 
The foundation for quality in nursing practice is the planning and delivery of personalised or patient-centered care.

 

Nursing Care Plan Types

 

There are two types of care plans: informal and formal. 
An informal nursing care plan is a mental strategy for the nurse to follow. 
A formal nursing care plan is a written or electronic document that organizes the information about the client’s care. 
Standardized care plans and personalized care plans are two types of formal care plans: 
Nursing care for groups of clients with common requirements is specified in standardized care plans. 
Individualized care plans are created to fulfill a client’s special demands, as well as needs that aren’t met by a typical care plan.

 

Objectives

 

The goals and objectives of establishing a nursing care plan are as follows:

 

Promote evidence-based nursing care in hospitals and health centers, as well as make the environment pleasant and familiar.

 

Support holistic treatment, which considers the full individual, including their physical, psychological, social, and spiritual well-being, when it comes to disease management and prevention.

 

Create initiatives such as care routes and packages of services. 
Care paths entail a collaborative effort to reach a consensus on standards of care and expected outcomes, whereas care bundles are based on best practices for treating a specific disease.

 

Goals and expected outcomes should be identified and distinguished.

 

Examine the care plan’s communication and documentation.

 

Nursing care should be measured.

 

A Nursing Care Plan’s Goals

 

The following are the reasons for writing a nursing care plan and how important it is:

 

Defines the role of the nurse. 
It assists in recognizing the unique role of nurses in catering to clients’ total health and well-being without relying just on medical instructions or interventions.

 

Provides direction for the client’s tailored care. 
It enables the nurse to reflect critically on each client and devise solutions that are specifically customized to them.

 

Continuity of care is important. 
Nurses from different shifts or floors can use the data to provide the same level of care and interventions to clients, ensuring that they get the most benefit from their therapy.

 

Documentation. 
It should specify which observations should be made, what nursing actions should be taken, and what instructions the client or family members require. 
There is no evidence that nursing care was provided if it is not properly documented in the care plan.

 

It’s used to allocate a certain staff member to a specific client. 
There are times when a client’s care must be given to a staff member who possesses specific and precise expertise.

 

It acts as a reimbursement guide. 
The medical record is used by insurance companies to calculate how much they will pay for the hospital care that the customer received.

 

Defines the client’s objectives. 
It benefits not just nurses but also clients by allowing them to participate in their own treatment and care.

 

Components

 

Nursing diagnoses, client concerns, expected outcomes, and nurse actions and rationales are typically included in a nursing care plan (NCP). 
These elements are described in further detail below:

 

Assessment of the client’s health, medical results, and diagnostic reports 
The first step in creating a care plan is to determine your needs. 
Physical, emotional, sexual, psychological, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental aspects of client assessment are all taken into consideration. 
In this field, information can be both subjective and objective.

 

The client’s expected outcomes are defined. 
These could be long-term or short-term.

 

The care plan includes a list of nursing interventions.

 

Interventions must have a rationale in order to constitute evidence-based care.

 

Evaluation. 
The outcome of nursing interventions is documented in this record.

 

Formats for Care Plans

 

Nursing care plan forms are typically divided into four columns: nursing diagnoses, planned objectives and goals, nursing actions, and evaluation. 
Goals and assessment are in the same column in some agencies’ three-column plans. 
Other organizations use a five-column layout that includes an assessment cues column.
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