Most of client based nursing you will come across whether it is in a hospital or at home is based around good solid care planning. This is a list of instructions to ensure the patient either recovers from an illness or is maintained at their optimum level of health. Without care plans nurses would have no guidelines or framework to work around. And there would be a hell of a lot of confusion by all parties concerned. Therefore you will need to become somewhat of an expert at them if you are to be the super efficient nurse that you desire to be.
One of the main concerns of student nurses is the basic question „How do I write a good care plan? Care plans are sometimes too over elaborate or too vague. What I have included here is a framework that simplifies the A.P.I.E process. (Assessment, Planning, Implementation and Evaluation). If you remember to follow it then writing care plans will become second nature and not as difficult as at first seems.
First of all you must gather all the information that leads to the diagnosis of the patient and its resolution. Divide this into two lists Subjective data and Objective data. Secondly discard all other information not relevant to that diagnosis. In the subjective data include
Client complaints
Description of theclients support system
Behavioral and non-verbal messages
Clients awareness of his/her own abilities or disabilities, disease process, prognosis, health care needs, and available resources.
In the objective data include relevant
Physical assessments including vital signs e.g. Blood pressure.
Observations of the support system in action
Judgment of the clients readiness for learning
Chart information including test results.
After the assessment stage is the diagnosis.
When writing a plan with several diagnosis write the diagnosis with the highest priority first.
Secondly select diagnosis that you can actually resolve. Write out the three parts of the diagnosis. (R.E.D). R= the human response to the diagnosis e.g. Anxiety E=Aetiology or related factors/events
D= Data that supports the diagnosis
Number each goal stating the goal, the tool to measure the goal and the time to evaluate.(G.T.T)
The goal must be stated in terms of client achievement e.g. Reduction in anxiety
Each goal must be measurable.eg. 1-10 (anxiety rating tool) Each goal must have a target date
Write at least one short term goal for every diagnosis Write at least one long term goal for each plan.
After each goal list specific nursing actions used to work toward the goal.
Nursing actions must be specific
After each nursing action cite the source of the scientific rationale.
The rationale must be logical and relevant
State when the plan was evaluatedeg.9/3/2005
Draw conclusions e.g. helping the client to talk about their feelings reduced the sense of isolation.
Consider changes/additions to the interventions.
State when the next evaluation is eg.9/4/2005.