Preparing a nursing care plan can provide valuable treatment information.
Care plans are medical documentation that serve as a record of a patient's medical condition, as well as the patient's ongoing treatments, the reason the treatments are being done, and the expected outcome from the treatment plan. The care plan can also list any risks associated with the injury or condition, other details about the patient's condition, and comments about the patient's immediate care.
Instructions
1. Assess the patient properly, determining the patient's injury or medical conditions. Assess the vital signs as well as signs of other conditions or medical problems, such as breathing difficulties. Evaluate the patient's pain severity and determine the characterization of the urinary output, including volume. Determine the severity of the injury or condition. Listen to the bowel sounds.
2. List the nursing diagnosis of the patient's condition or injury. Each individual diagnosis should have its own nursing care plan, because each medical condition will have different treatment plans and rationales for performing them, just as every patient diagnosis will have different expected outcomes.
3. List all of the patient's necessary medical treatments or interventions and the rationales for performing each one. It is vital that there be a sound medical reason given for doing each treatment, and everything must be included on the nursing care plan.
4. List the patient's expected outcome from each injury or medical condition. The nursing care plan should reflect the expected outcome at the time of the patient's discharge, and whether it was able to be met as expected.
5. List any health risks from the injury or condition if proper care is not provided, along with comments about the patient's immediate condition.
Tags: care plan, about patient, expected outcome, injury condition, medical condition