Nursing Care Plans: Diagnoses, Interventions, A...
Free care plans list: Browse our care plan database for nurses and nursing students below to learn more about how care plans are arranged, organized, and created. We have placed these care plans online so that nursing students (and pre-nursing students) can get an idea of how care plans are created, and what care plans will look like in nursing school. These are meant for educational purposes only, and are not designed to be actual treatment protocols for patients.
Nursing Care Plans: Diagnoses, Interventions, a...
While we encourage nursing students to view these care plans to help them understand how they are developed (and to practice creating them), students should never copy them as their own homework. It is very important to learn how care plans are created, as this is a vital part of the nursing process--even though they can be tedious to complete in nursing school. If you want to learn more about care plans, please see our nursing care plans article.
NANDA-I adopted the Taxonomy II after consideration and collaboration with the National Library of Medicine (NLM) in regards to healthcare terminology codes. Taxonomy II has three levels: domains, classes, and nursing diagnoses.
The terminology is also registered with Health Level Seven International (HL7), an international healthcare informatics standard that allows for nursing diagnoses to be identified in specific electronic messages among different clinical information systems.
While all important, the nursing diagnosis is primarily handled through specific nursing interventions while a medical diagnosis is made by a physician or advanced healthcare practitioner.
Family nursing interventions are those that address not only the patient, but other family members as well. They could entail education of family members about caring for the patient; or, in the case of new mothers, interventions could consist of instruction and assistance with breastfeeding and other forms of infant care.
On-duty nurses routinely perform certain nursing interventions as part of their daily tasks. In addition to educating the patient on their care and recovery progression, nurses will typically perform the following each shift:
Creating a safe environment, promoting good health practices, and listening closely to patients are daily nursing interventions you will perform and perfect throughout your career as a nurse. If you aspire to a nurse leadership role, such as a nurse practitioner, nurse manager or executive, you may eventually oversee and strategize care plans for hundreds of patients. With an advanced career in nursing, you can lead initiatives to improve the quality of care and make lasting, positive impacts on patient lives.
Care plans are part of the core curriculum in most nursing schools. Yet, new hospital nurses often complain that despite all the hype and time spent learning how to make a nursing care plan, they never do it again after graduation. As a nursing leader, you might not have written one for a while, either. Why should you start now?
Care plans help nurses focus on patients in a holistic, big-picture way so they can deliver evidence-based, patient-centered care. Care plans also help hospitals ensure continuity of care across nursing shifts, promote inter-professional collaboration by getting everyone on the same page, and meet documentation requirements for insurers and governing bodies.
Long-term care providers such as nursing homes, mental health facilities, and home health nurses typically use formal care plans, and they are often required to do so by governing bodies like the Joint Commission. Yet, in hospitals, care plans often fall by the wayside.
Finally, the nurse monitors and evaluates the patient and the nursing care plan on a regular basis to answer the question: Are the nursing interventions helping the patient reach their goals and desired outcomes, and should those interventions be changed, terminated, or continued?
For care plans to be useful, they need to promote effective communication in nursing. They need to be shareable, easy to access, and always up to date. That means they need to be electronic, and preferably integrated into the EHR for cloud access and real-time inter-professional collaboration.
The bestselling nursing care planning book on the market, Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8th Edition covers the most common medical-surgical nursing diagnoses and clinical problems seen in adults. It includes 217 care plans, each reflecting the latest evidence and best practice guidelines. NEW to this edition are 13 new care plans and two new chapters including care plans that address health promotion and risk factor management along with basic nursing concepts that apply to multiple body systems. Written by expert nursing educators Meg Gulanick and Judith Myers, this reference functions as two books in one, with 147 disorder-specific and health management nursing care plans and 70 nursing diagnosis care plans to use as starting points in creating individualized care plans.
In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.[1][2][3]
A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions. Thus, they are at the base of Maslow's pyramid, laying the foundation for physical and emotional health.[4][5]
Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.
This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.
According to a 2011 study conducted in Mekelle Zone hospitals, nurses lack the knowledge to implement the nursing process into practice and factors such as nurse-patient ratios inhibit them from doing so. Ninety percent of study participants lacked sufficient experience to apply the nursing process to standard practice. The study also concluded that a shortage of available resources, coupled with increased workloads due to high patient-nurse ratios, contributed to the lack of the nursing process implementation in the delivery of patient care.[6][7][8]
The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.
Use of a standardized nursing language for documentation of nursing care is vital both to the nursing profession and to the bedside/direct care nurse. The purpose of this article is to provide examples of the usefulness of standardized languages to direct care/bedside nurses. Currently, the American Nurses Association has approved thirteen standardized languages that support nursing practice, only ten of which are considered languages specific to nursing care. The purpose of this article is to offer a definition of standardized language in nursing, to describe how standardized nursing languages are applied in the clinical setting, and to explain the benefits of standardizing nursing languages. These benefits include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. Implications of standardized language for nursing education, research, and administration are also presented.
Recently a visit was made by the author to the labor and delivery unit of a local community hospital to observe the nurses' recent implementation of the Nursing Intervention Classification (NIC) (McCloskey-Dochterman & Bulechek, 2004) and the Nursing Outcome Classification (NOC) (Moorehead, Johnson, & Maas, 2004) systems for nursing care documentation within their electronic health care records system. ...it is impossible for medicine, nursing, or any health care-related discipline to implement the use of [electronic documentation] without having a standardized language or vocabulary to describe key components of the care process.During the conversation, one nurse made a statement that was somewhat alarming, saying, "We document our care using standardized nursing languages but we don't fully understand why we do." The statement led the author to wonder how many practicing nurses might benefit from an article explaining how standardized nursing languages will improve patient care and play an important role in building a body of evidence-based outcomes for nursing.
Practicing nurses need to know why it is important to document care using standardized nursing languages, especially as more and more organizations are moving to electronic documentation (ED) and the use of electronic health records. In fact, it is impossible for medicine, nursing, or any health care-related discipline to implement the use of ED without having a standardized language or vocabulary to describe key components of the care process. It is important to understand the many ways in which utilization of nursing languages will provide benefits to nursing practice and patient outcomes. 041b061a72