What Is a Nursing Plan?
A nursing plan is a document that provides strategic direction on the nursing care plan for your patient's needs. It contains all relevant information on your patient's diagnoses, treatment, and evaluation. This has been used for quite some time to promote health care to them.
How to Make a Nursing Plan
Research shows that inaccurate and delayed diagnoses have great effects on patient care, and have harmed an acceptable number of patients. How did this happen? The culprit is a poorly written nursing plan. Poor communication by the staff inside hospitals and clinics leads to a chaotic environment. Which is why it is highly important to have a clear and consistent nursing plan to avoid these circumstances.
1. Gather All Information
Gather all important information for your nursing plan. Talk to the patient and their loved ones about the situation, and ask their consent to get your needed data. Once they agree, get a head-to-toe assessment from your patient’s body, and observe their lab values and vital signs. Create a report about your observation and list it down. Chart your reviews and take note of your observations.
2. Analyze the Situation
After your health care team members discuss the entire information, check the areas the patient has troubles with and find ways to improve their conditions. At the same time, identify ways on how to spot improvements on their conditions. List down these general issues, and focus on how you may progress with the given data you have.
3. Think about the Issues Involved
Identify how the information was given to you. Decide if it is a subjective observation or an objective observation. Did the patient tell you personally about his or her pain? Or was it through observation that you were able to spot the pain? Check if he or she had undergone medications or is still in the process of his or her medications. Indicate all your reasons behind the problems identified, then provide your interventions as well as your evaluations.
After everything is settled, take your textbooks and reference materials, and look up the official terms of the problems. List them down and look for outcomes and interventions that align with the problems written. As much as possible, use layman's terms in writing down your sample report. If you haven’t noticed, medical terms are quite hard to understand, especially for people who are not quite inclined with its language.
Once you finished translating every technical term into layman’s terms, proceed to transcribing your task plan. Put the pieces together, check how the problem relates to the factors affecting the situation, then define its characteristics. Once you complete the task, provide answers on how you may be able to work with the problem. Lastly, create your nursing diagnosis on the problem, then insert your interventions, outcomes, and evaluation on the situation.
Of course, don’t forget to review. Mistakes are inevitable, but you are dealing with the lives of your patients. Which means, errors are critical and must be corrected at all cost. Review your nursing plan before you actually submit it to a head doctor and diagnose your patient.