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How do you do a Nursing Care Plan Essay

1. Perform a physical examination of the patient

   When developing a nursing care plan strategy, the nurse begins by reviewing all relevant data, which may include, but is not limited to, medical history, lab results, vital signs, data from a head-to-toe assessment, conversations with the patient and their loved ones, observations from other members of the care team, and demographic information. The following information is used by the nurse to evaluate the patients:

   1.     Needs in terms of physical, emotional, psychological, and spiritual health
   2.     Areas that require improvement
   3.     Factors that increase the risk

2. Identify and list the nursing diagnoses

   Nurses identify nursing diagnoses after conducting an in-depth examination of the patient’s condition. Nursing diagnoses are health problems or possible health problems that nurses can treat without the need for medical involvement. Nursing diagnoses include, for example, acute pain, fever, sleeplessness, and a danger of falling, among other things. Each diagnosis on the official nursing diagnostic list is curated by the North American Nursing Diagnosis Association (NANDA), which provides definitions, characteristics, and commonly used interventions for each diagnosis. These diagnoses serve as the foundation for implementing the necessary health reforms.

3. Establish objectives/best outcomes for the patient

   What are the desired goals, and what strategies will be used to get the patient there? The nurse responds to these questions depending on the evaluation, the nursing diagnosis, and input from the patient, among other factors. It will be critical to clearly define the goals and objectives of the proposed health-reform plan in advance. Together, the nurse and the patient establish realistic goals that can be met through nursing interventions and (in certain situations) personal effort on the part of the patient. Aims can be short-term (e.g., alleviating acute pain after surgery) or long-term (e.g., lowering the patient’s A1C with improved diabetes care). The nurse then prioritizes goals based on the value of the goals, the urgency of the goals, and patient feedback. In addition, nurses can use Maslow’s hierarchy of needs to assist them in prioritizing a patient’s goals.

4. Put nurse interventions into action

   In a health reform plan, nursing interventions are the most important components because they describe the actions taken by a nurse to achieve patient goals and achieve desired outcomes — for example, administering medications, educating the patient, checking vital signs every couple of hours, initiating fall precautions, or assessing the patient’s pain levels at specific intervals. Nursing documentation is done here as well; and includes documentation of any dependent nursing interventions that are required by physicians.

5. Evaluate, monitor, and make adjustments to the care plan.

   In the end, the developed health reform plan will be incomplete unless the nurse monitors and evaluates the patient and the nursing care plan on a regular basis in order to answer the question: Are the nursing interventions assisting the patient in achieving their goals and desired outcomes, and should the interventions be changed, terminated, or continued?

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